HomeMy WebLinkAboutWell New 218 Buckland Road CPR-8 Rev.7/95 PERMIT NUMBER
} STATE OF CONNECTICUT 242958
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING-:PERMIT
`. 165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lot Number) __TDATE
South Windsor 218 Buckland Street 9-23-0$
OWNER OF WELL
® INDIVIDUAL a BUILDER ❑ OTHER(Specify)
OWNER S ADDRESS 4_4"4245
Craig & Lynn Kochanski 15 Grandview Terr. S.Windsor 559-5140
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL I_ I .-. # . wellPUBLIC .
w SUPPLY INDUSTRIAL [2-CONDITIONING AIR sT�ty) absnr30 went
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 to and to house(if present)
c pe. C.
1 celd A r Hue,
Indicate North
Lo
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware t u o letion of the well, a"Well Completion Report"containing construction details and information required under
Section 25-131 of the 1 pie t to the General Statutes must be sent to the owner, the Department of Consumer Protection and the Water
Resources Commiss' the f provided by the agency. This permit is not valid until all information is filled in and it has been counter-signed by
the Director of He r his a
APPLICANT(Si ) APPLICANT'S ADDRESS REGISTRATION NO.
Jo to nS .O: ox 406 Willing1ton 42
= B (T l Ofc or Agent) DATE
E. 6APPROVED ❑ REJECTED EF
I
E.
REMARKS
DIRECTOR OF HEALTH
STATF OF CON.NECTICUT
DEPARTMENT OF CONSUME.�R PR0Tr,'CT10N
REAL E.S'TA"rE &, PIx0 FESS IONA I.-TRA 1)b',S
WELL ABANDONMENT, VERIFIC"ATION OP- 1VORK COMPLETED
All procedures Used to abandun a well shall follow J-CCFL1h'1Ci011S established under
Seerioyi 25-128-56 and 25-128-57 of the State of Connecticut Well Drilling Board Regulations (see attach-
6
111dill). These regulations require that a registered well drilling contractor perform the work.
0 t"
Vor water suppiv wells attach completed form to Well Permit, For non-water stipply wells attach sketch
of Well location to completed form. Distribution: Department of Consun-ier Protection, Department of
1"livil-orlinultal Protection, Property Owner, Well Drilling Contractor,
"'ell
Date 1vork completed: 10 —
Name of Owner: CS7�Q.
Address: C-
j
Localit)" 01'%vell (if different from above): P PA
Type of well (drilled, point, dug;,.etc.): d! tci
�U Deptl I QQ
ffitt
al-never of well: Length of casin-:
Work details and other information:
Name 01'registered well drilling contractor p erforining work:
Registered well drilling contractor's license type
W3-#
Materials used: 111-nount of sand
al-41ount and type(s), of groutQ
�(AZ
I)escription ofivork completed: L L
Stoned:
----------- (well drilling contractor)
'16.5 Clipitul Avenue, HdWURI, C"(3 rtnec Licit 1 06106-11)3(1
Fox: (860) 566-7630 o TDD: (860) 566-1547
;In Affirt-native hI/ j EIII.rloy