HomeMy WebLinkAboutWell New 80 Berle Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
' S-' 11-6' WELL DRILLING PERMIT 327
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (roeon) (Street) (Lot Number) DATE
S. jV1AJPJb)C % 4 C, W4
OWNER OF WELL
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER`S ADDRESS
G�"rr go AssAJ! Cot,v �?"' .4:
PROPOSED DOMESTIC ❑ BUSINESS TEST Est.No.of
ESTABLISHMENT ❑ TARN ❑ WELL People being
USE OF served.
WELL PUBLIC AIR OTHER El ❑ INDUSTRIAL ❑ CONDITIONING ❑ (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
amerce- ,ei, .
Approximate number of feet from well to ,�r,r./
nearest source of possible contamination: 7(�
The undersigned is aware that upon completion Of the well,a' Nell 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.
APPLICANT(Stynatu ) APPLICANT'S ADDRESS
, � I �&� 71 I REGISTRATION NO.
671 8y n S h 0 J{cer or gent) DATE
APPROVED ffOREJECTED
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD STATE WELL NO.
State Office Building q
HARTFORD,CONNECTICUT 06115 3 W t _ -
OTHER NO.
NAME I ADDRESS '
OWNER r t
W/ 3 3", Lf f'1 t 1' 1' h•r) rf
LOCATION (No.&Street) (Town) (Lot Number)
OF WELL —:Beh n i f I^s, s --
PROPOSED
DOMESTIC ❑ BUSINESS
SHMENT El FARM El TEST WELL
USE OF
WELL PUBLIC AIR❑ OTHER
SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING COMPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY L 1 AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
CASINDETAIlS
HREADED ❑ WELDED ES ❑NOES ❑NO
HOURS YIELD(G.P.M.)
YIELD TEST ❑ BAILED ElPUMPED COMPRESSED AIR
MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet) Depth of Completed Well j ^'�
,LEVER s I I in feet below Land surface: !r .rT a�+�
MAKE I 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 pack(inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
D Gary
C—d tr A LV
f
%'04
I
deft L
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
r".
DATE WELL[COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature) e 1 f C
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