HomeMy WebLinkAboutWell New 17 Brookfield Street t�l e I wee+ 999
CPR-B Rev.7/95 PERMIT NUMBER
STATE OF CONNECTICUT 197180
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING:PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCIAON
OuTr!LL l�l/fivAso/t `YJt1PQU77 /d- tlo�q 17 j.QATE'
—ZC —7 9 -
f�,QW'�N. WELL ,.,
��jk/C ���K INDIVIDUAL 'a BUILDER OTHER(Specify)
OWNER'S ADDRESS
Est.No.of
PROPOSED �OMESTIC El BUSINESS FARM TEST People being
USE OF ESTABLISHMENT VVELL served.
_ WELL
SPUBLIC UPPLY INDUSTRIAL I C OTHER
CONDITIONING a �.
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,s owing distance from intersection and-front of lot
location of lot to at least two roads Well location on to and to house(if present)•-
L4
Indicate North ` Zf <
tD C/
Ac
p1 Q. cs
b -
CtIkthf e^ lI JL
Approximate number of feet from well to
nearest source of possible contamination: jf� 7 ff f/&�Pl�✓
- The undersigned is aware that upon completion of-the well,a Well C15mpletion Report"containing construction detallis and information required-under
:.Section 25-131 of the 1969 Supplemen to the.General,Statutes must be sent to the owner,the Department of Consumer Protection and the Water
-Resource m •ssio on the form p A the envy. This�I�ryt rs vali til•all information is filled in and it has been counter-signed by
the or of a his llilj 0�� X 17,j%njf
LI (Sign ) APPLI TS ESS REGISTRATION NO.
° /I -
BY(Town Heafth 0 ter orAgent) DATE
PROVED REJECTED
. ._ Cam' ❑ /e-D • �l�--Q� .
REMARKS
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
�. WR-9 Rev.7/95
STATE OF CONNECTICUT STT NOT fill O.
NOT
WELL N0.
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING COMPLETION REPORT OTHER NO.
165 Capitol Avenue,Hartforc. -.k aecticut o61 o6
OWNER NAME
ADDRESS
7/vo 71
LOCATION (No.a Street) (T j� /_, (Lot Number) 7 ,,
OF WELL C1K eel Ad 1T �J# / i� 607�
DOMESTIC ESTABL SHMENT a FARM LiWELL
PROPOSEDof
USE OF WELL
PUBLIC SUPPLY INDUSTRIAL AIR OTHER
11 CONDITIONING (Specify)
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT 11 AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT
DETAILS /�`6) {�j' /7 IVE SHOE WAS fNGGROUTED?
THREADED ❑ WELDED
YIELD TEST F]BAILED PUMPED COMRESSED AIR HOURS YES ❑ N0
P YES ❑ NO
YIELD(GPM) f
f
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well in feel
LEVEL
MAKE 2,90
SCREEN LENGTH OPEN TO AQUIFER(feet)
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well
GRAVEL SIZE(inches) FROM(feet' TO(feet)
PACKED: including gravel pack
(inches)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION
Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
I=
> 1
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE r
WVj
DAT WELL COMPLETED P_LRMIT NO.�# REGISTRgN N0. A OR PT
l DRILLE ign
DEPT.OF ENVIRONMENTAL PROTECTION-WATER RESOURCES