HomeMy WebLinkAboutWell New 150 Berle Road WELL MLLING$OARD STATE OF CONNECTICUT - PERMIT NUMBER
wDB a 111-69 WELL DRILLING 'PERMIT 11834
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATI OF WEl own) (Sheet) (lot Neimberj 170
OWN OF
DTVIDUAL ❑BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑.FARM El WELL People being
USE OF served.
WELL ❑ PUBLIC AIR OTHER SUPPLY ❑ 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)
fi •
Indicate North
R
Approximate number of feat from well ^
nearest source•of possible contamination:
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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 ow'der,the Board and the Water Resources Commission on the form provided by the Board.This
pe it is not Vic!untilAl information is filled in and it has been cw�nt—- ned by the.Director of Health or his agent.
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( ahnej APPLJ _DDRESSI///fj REGISTRAIJON NO.
BY(Town Heafth Officer or Agent DATE
❑APPROVED ❑ REJECTER
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD`
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-5 12-69 REV. 9.71 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115 S(A.1 f (
ttx` OTHER NO.
OWNER NAME ` I ADDRESS
LOCATION (Nn. R Strew
OF WELL 1� � ` Rovy s^ (Lot Number)
PrDOMESTIC BUSINESS r
`PROPOSE® ❑ ESTABLISHMENT ElFARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR ElSUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ ((SSpecfy)
DRILLINGROTARY {COMPRESSED ❑ CABLE El (Specify)
EQUIPMENT I�l AIR PERCUSSION PERCUSSION (Specify)
CASING
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
I Y I I I DETAILS � THREADED ❑ WELDED DYES ❑ ❑NO YES ❑NO
YIELD ❑ BAILED ❑ PUMPED HOURS YIELD(G.P.M.)
TESTCOMPRESSED AIR I / , t
MEASURE FROM LAND SURFACE—STATIC(Specify feet) y
WATER I DURING YIELD TEST(feet) I Depth of Completed Well
LEVEL in feet below Land surface: 'Pee
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including I
GRAVEL SIZE(inches)IF
(feet) ITO(feet)
PACKED: I gravel pack(inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances,to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
V
i-
L
YC
if yield was tested at different depths:during drilling, list below U
FEET GALLONS PER MINUTE Lc��/
DATE WELL COMPLETED' PERMIT NO..3 REGISTRATION NO. DAArT�E OF REPORT WELL-DRILLER (§ nature)
DEPT. OF ENVIRONMENTAL PROTECTION