Fillable Massachusetts Department of Transport Salt Remediation Program Private Well Data Form Environmental Services

Fill Online, Printable, Fillable, Blank Massachusetts Department of Transport Salt Remediation Program Private Well Data Form Environmental Services Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Massachusetts Department of Transport Salt Remediation Program Private Well Data Form Environmental Services

On average this form takes 13 minutes to complete

The Massachusetts Department of Transport Salt Remediation Program Private Well Data Form Environmental Services form is 2 pages long and contains:

  • 0 signatures
  • 36 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
ENVIRONMENTAL SERVICES
Salt Remediaton Program
Private Well Data From
I. Owner Information
Owner Name:
Home Phone:
Address:
Work Phone:
City/Town
Cell Phone:
Zip code
Email Address:
Date Property Purchased:
II. Occupants(s)
Name(s):
Number of Occupant(s) using well:
Address at Well Location:
Home Phone:
City/Town:
Zip code:
Work Phone:
III. Well Type and Use
Well Water Use: (you may choose more than one):
Domestic Agricultural Commercial Industrial
Irrigation Other (specify):
Drilled: Dug: Driven: Other (specify):
Estimated Daily Water Usage for
all purposes in gallons per day:
IV. Well Data
Well Depth:
actual estimate
Screened Interval:
actual estimate
Well Diameter:
actual estimate
Well Yield (gpm):
actual estimate
Well Casing Depth:
actual estimate
Depth to Bedrock:
actual estimate
Well Casing Material:
actual estimate
Date Well Constructed:
actual estimate
Type of Pump: Submersible Jet Shallow Other (specify):
Pump Intake Depth (bgs):
actual estimate
Nominal Pump Capacity (gpm):
I have enclosed a copy of the Well Completion Report and/or Well Driller invoice : yes no
Driller’s Name:
Driller’s Phone:
Driller’s Address:
V. Water Quality
Describe water problems:
When did you first notice water problems?
Did you attach a water analysis from a MassDEP certified laboratory for: Sodium, Calcium,
Chloride, and specific conductance.
Yes No
Date(s) water samples were collected?
If accepted into the program would you like to receive copies of future water
quality results?
Yes No
If Yes, Certified Mail Email
VI. Water Treatment
Do you have any water treatment or filtration equipment? Yes No
If you answered Yes above, include copies of the bills from the installer and the company that services the equipment and
complete the following information.
Name of Installer:
Phone Number:
Neutralizer:
Softener:
Other(specify):
How much salt is used each year in your water softener?
(pounds)
What chemical is used in your neutralizer?
(pounds)
VII. Diagrams
Attach a Site Map showing the information listed below. You may find a plot plan or site map on file at your local
assessor’s office or board of health.
• The location of all property structures, well and septic system including the leaching field;
• The location of all abutting properties wells, septic systems, and leaching fields
• The state highway(s)
VIII. Certification
I hereby certify that all of the statements and information on and supplied with this application form are true and complete
to the best of my knowledge and belief and that no information necessary to the resolution of this complaint is withheld.
Owners Signature:
Date:
Signature of Person Preparing this Form:
Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Massachusetts Department of Transport Salt Remediation Program Private Well Data Form Environmental Services

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document