HomeMy WebLinkAboutWell New 839 Avery Street WKI COMPLETION REPORT • STATE OF CONNECTICUr Do NOT fill in
WDB-5 72.69` REV.9-71 WELL.DRILLING BOARD
State Office Building
STATE WELL NO.
HARTFORD, CONNECTICUT 06115
OTHER NO.
NAME ADDRESS
OWNER PIEILV I � S. W-MS0119 am.
LOCATION (No.&Street) (Town) (Lot Number) -
OF WELL AV= 82. som
L M11
BUSINESS
PROPOSED DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC OTHER
❑ SUPPLY El- 1DUSTRIAL ❑ CO IONING ❑ (Specify)
DRILLING ® ❑ COMPRESSED ❑ CABLE ❑ OTHER
ROTARY. AIR PERCUSSION (Specify)
EQUIPMENT 4 PERCUSSION
CASING LENGTH (feet) DIAMETER(inches) WEIGH PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS 45 I I '� # I THREADED ❑ WELDED I 91 YES ❑NO ❑YES ®NO
HOURS YIELD(G.P.M.)
TEST
YIELD ❑ BAILED ❑ PUMPED ® COMPRESSED AIR I O 18
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)WATER Depth of Completed Well
*�
LEVEL I i in feet below Lend surface: 1
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL I Diameter of well including
(GRAVEL SIZE(inches) FROM(feet) ITO(feet)
PACKED: gravel pack(inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location Of well with distances,to at least
FEET to FEET two permanent landmarks.
0 2 Topsoil
Rod Ro*k
( 1it I �r
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
s� r
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT EL DR (Sign e)
9/23/74 1 �t3 1Q0 913017
LOCAL" DIRECTOR OF HEALTH
_ -�}`rrµ•'j. „^ ' "+ "„7,.�
i
WER 1DithING BOARD r STATE OF CONNECTICUT PERMIT NUMBER
WD" 11.69 WELL DRILLING PERMIT 24440
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL (Town) (Street) (Lot Number) I DATE
SOUTH WINDSOR AVERY ST. 7/23/74
OWNER OF WELL
INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) PHILIP M. CHOMA
OWNER'S ADDRESS
65 TUMBLEBROOK DRIVE, SOUTH WINDSOR, CONN.
PROPOSED BUSINESS TEST Est.No,of
DOMESTIC El ESTABLISHMENT ❑ FARM ❑ . NELL _ People being
USE OF served.
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING of JSpec fy) 4 6"
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' T Well.location on lot and-to house(I present)
Indicate North
itp
0 d v aJ'6
�40
LAO
71
�9 u .I'T.
Approximate number of feet from well to
nearest source of possible contamination: 80
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 on the form provided by the
Board. This permit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent.
ICANT ignat pre) APPLICANT'S ADDRESS REGISTRATION NO.
T-A ST. ,_YRRNON, COIN. I 104
BY(Town Heabth O ' r or Agent) I DATE
FfeAPPROVED ❑ REJECTED
REMARKS
I
it
DIRECTOR OF HEALTH