HomeMy WebLinkAboutWell New 42 Barber Hill Road C014SUMER PROTECTION
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT.NUNIBER
CPR-8 aev.it-ex DEPARTMEAtj OF�CONSUMER PROTECTION 148149
WELL DRILLING PERMIT
165 CAPITOL AVE.,HARTFORD,CONNECTICUT 06106
LOCATION OF WELL(7' ) (Street) (Lot member) DATE
/71
OWN
OF WELL
jes
NINWOUAL BUILDER �• OTHER(Specify)
OWMIER'S
�--� / r BUSINESS TEST Est.No.of
PROPOSED I/V60ME>iTTC ESTABLISHMENT WELL WELL People being
USE OF PLISILIC AIR's4r� served.
WELL SUPPLY INDUSTRIAL CONDITIONING (SpecifyQ OTHER)
SKETCH OF WELL LOCATION
Locate well with respect to of-least two roods,showing distance from intersection and front of lot
Location of lot to of Lost two roads Well
location on lot and to house (if present)
Indicate North 4- W"
V
-
v � f
Apprositnote number of feet from well to x
nearest source of possible contamination:
The;undersigned is aware that.upon completion of, the,well,•a "Well Completion Report". containing construction details and information•required'under Seddon
25-131 of.the 1969 Supplement to the.General Statutes.must be lent.to the.owner,•the,Board and the Water Resources Commission on the form'provided by the
This rmit is trot valid until for tton is filled in ond•is hos been counter-signed by the Director of Health-or his agent.'
ire APPLI NT' ADDRESS _ REGISTRATION NO.
BY(Town Health Officer or.Ageet) jr DATE.
Q—APPROVED p RE)ECTED
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL.DRIL UNG BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
CPR-4 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in
WELL DRILLING BOARD STATE WELL NO.
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME ADDRESS
OWNER
LOCATION (No.& Street) (Town) (Lot Number)`
OF WELL 1 �i
PROPOSED DOMESTIC STSABLISHMENT El FARM TEST WELL
USE OF
WELL PUBLIC I
SUPPLY INDUSTRIAL CONDITIONING OTHER
(Specify)
DRILLING ESSED CABLE OTHER
KU~NT ROTARY AIR PERCUSSION .PERCUSSION ❑(Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT j I H WAS CASING GROUTED?
DETAILS �HREADED WELDED ES NO ES NO
YIELD HOURS YIELD (G.P.M.)
TEST BAILED PUMPED COMPRESSED AIR r
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL ?' 0 in feet below Land surface:
MAKE LENGTH OPEN TO AQUIFER (feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feet
PACKED: gravel pork (inches}:
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET TO FEET two permanent landmarks.
�P ff �a _
t
3
(i f j
1
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE 1
DATE COMPLETED PERMIT NO. � REGISTRAT70. DOF REPORTWELL D f (Si ur
D< .? OF ENVIF?4?'aMENTBAL.PROTECTiON-lb-A ER RE-so rte°ES
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