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WELL DRILLING BOARD � � � � STATE OF CONNECTICUT PERMIT NUMBER
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DS4 11-6' WELL DRILLING PERMIT 18027
STATE OFFICE BUILDINO,HARTFORD,CONNECTICUT 06115
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LOCATION
OF WELL(Town) (Street)I (Lot Number) DATE.
OWNER OF WELL
❑INDIVIDUAL BUILDER a.OTHER(Specify)
OWNER'S ADDRESS
PROPOSED Imo}�MIC ❑❑ BUSINESS a _ TEST Est.No.of
USE OF Ll(J ESTABLISHMENT FARM WELL People being .
served.
WELL PUBLIC
SUPPLY INDUSTRIAL CI CIONDITIONING 0 OTHER
(specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
Location of lot to at least two roads Well location on lot and to house(if present)
Indicate North
L �D
. I
Approximate number of feet from well to 5 �O
nearest source of possible contamination: �p
The undersigned is aware that upon completion of the well,a"Well Completion Report".containing construction details and information required under Section 25.131
of the 1969 Supplement to the General Statutes must be sent to the owner,the Board and the Water Resources Commission an the form provided-by the Board.This
permit is not valid Mil a I information is filled and it has been counter-signed by the Director of Health or his agent.
Go rrSdys .
(Signature) ' APPLICANT'S ADDRESS REGISTRATION NO.
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tom..'t'�- '.- w BY own Ith fficer nt) -ATE
PPROVm ❑ REJECTS 3
REMARKS
REWN THIS COPY TO CONNECTICUT WELL DRILLING BOARD .'
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WELL COMPLETION REPORT STATE OF"CONNECTICYT :.
WD6-5 1244--REV.0.71 WELL DRILLING BOARD, Do NOT fill ffi
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115 ;
OTHtR:jNO.-
NAAAVf . ADD S
OWNER
LOCATION ' ( :Street) -(Town / (Lot Number)
OF WELL
BUSINESS
PROPOSED DOME C ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL :
USE OF
PUBLIC AIR OTHER
WEL ❑ SUPPLY ❑ INDUSTRIAL ❑-CONDITIONING ❑ (Specify)
DRILLINd COMPRESSED CABLE..- OTHER
EQUIPMENT ❑ ROTARY A R-PER USS101 ❑'PERCUSSION ❑ (Specify) '
CASING LENGTH(feet) DIAMETER(inches) WEIGHT-PER FOOT { DRIVE SHOE - WAS CASING GROUTED?
DETAILS =I Q: ( 2 I (L�J THREADED_ ❑ WELDED+ ' YES ❑NO% W YES ❑No .
HOURS -YIELD(G.P.M.) •"
• YIELD- - - -
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR
MEASURE FROM LAND SURFACE—STATIC,(Specify feet) DURING YIELD TEST(feet)•.
WATER i ` Depth of;Completed Wed
LEVEL f I in feet below Land surface:. ` D,
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN -
DETAILS •SLOT SIZE DIAMETER(inches) iF GRAVEL Diameter of well including: GRAVEL SIZE(inches)FROM(feet) ITO(feet)
PACKED: ` gravel pack Cinches): I
DEPTH FROM-LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well wiih'distances;to st least'
FEET to "FEET two permanent landmarks.
If yield was-tested at different depths'during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. ii REGISTRATION NO. DATE OF REPORT WELL,DR}LER(Signs 're)
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