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WELL COMPLETION REPORT STATE OF CONNECTICUr
WDB-s 12.69 .REV. vat WELL DRILLING BOARD Do NOT fill in
* State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115
OTHER NO.
NAME G I ADDRESS
OWNER ARLO P�' mL 69 ASH RD. s WAPIVIG C01f1f.
' LOCATION (No.& Street) (Town) (Lot Number)
OF WELL MaLlg ROAD S. WINDSOR 4
BUSINESS
❑ ESTABLISHMENT HMENT ❑ FARM
PROPOSED DOMESTIC ❑ TEST WELL
USE OF
WELL PUBLIC AIR
❑ SUPPLY ❑ INDUSTRIAL El CONDITIONING ❑ ((Spec fy)
COMPRESSEDDRILLING CABLE
EQUIPMENT ® ROTARY ❑ AR ER USSION ElP RCUSSION ❑ (Specify)(
CASING LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS 2 L I 6 I 19*45 I THREADED ❑ WELDED I YES [:]NO ❑YES NO
YIELD HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR I - 4 10
WATER MEASURE FROM LAND SURFACE—STATIC (Specify feet)I DURING YIELD TEST(feet) I Depth of Completed Well
LEVEL 25 $ in feet below Land surface: �00
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL I I GRAVEL SIZE(inches)(FROM(feet) ITO(feet)
Diameter of well including
PACKED: -gravel pack(inches):
DEPTH FROM LAND SURFACEI
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET
two permanent landmarks.
11
100— —
� s
t
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. I REGISTRATION NO. I DATE OF REPORT LL DRILLE isxhatu - s
7 �i
DIRECTOR OF HEALTH
w ..
WELL DRILUNG BOARD STATE OF CONNECTICUT PERMIT NUMBER
wD6-a, 11-69 WELL DRILLING PERMIT 18309
s ,
STATE OFFICE BUILDING,HARTFORD;CONNECTICUT 06115
LOCATION OF WELL(Town). (Street) Lot Number) DATE
OWNER OF WELL
❑ INDIVIDUAL BUILDER F—I OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
OMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELLAIR OTHER
❑11ZPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ `(Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at Feast two roads,showing distance from intersection and front of lot
e
`Location of lot to ,t)east two roads, Well location am lot and to house(if present) 11
Indicate.North.,....,„
1,00�/
WP
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware that uponcomple'on of the well,a"Well Completion Report"containQrtonstruction details and information required under Section 25-131
of the 1969 Supplement to the General S tutes must be sent to the owner,the Board and the Water Resources Commission on the form provided by the Board.This
perm] ' until all information is f'led in and it has 10en counter-signed by the Direct r of Health or his agent.
A PLICANI f5ign re) PPLICANT'S ADDRESS � REGISTRATION NO.
=BY own H Ith OCAr or Agent) DATE
APPROVED-`�" ❑ REJECTED
- REMARKS - - -- - -3
DIRECTOR OF HEALTH