HomeMy WebLinkAboutWell New 700 Burnham Street CPR-e Rev.7/95 PERMIT NUMBER
STATE OF CONNECTICUT 22.6892
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISIONL M 7
.
WELL DRILLING PERMIT
165 Capitol venue,Hartf rd,Conne ti ut 06106 ZZ2� aala:z��a j
LOCATI N WELL (Town) ( meU (Lot Number) q/ DATE
O EROF WELL
ElINDIVIDUAL P&OILDER OTHER(Specify) / -� p
OWNERS ADDRESS V 4^6_� �/T—�—S
Est No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served,
WELL
PUBLIC-SUPPLY INDUSTRIAL AIR a CONDITIONING •_ OTHER
EEM
SKETCH OF WELL LOCATION
Locate well with.respect to at least two roads,showing distance from intersection and fronttof lot
location of lot to at least two roads ' Well location on to and to house(rf resent)
t I
01
Indicate North - - -
0'
-Proximate number of feet from well to
nerest source of possible contamination:
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 owner, the Department-of Consumer Protection and the Water
Resources Commission on.the form 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 Health or his agent.
�(ftnafuno) APPLICANTS ADDRESS REGISTRATION NO.
BY(Town Heafth cerorAgenf DATE
❑ APPROVED ❑ REJE ED c
REMARKS_ n � (p' p
q3j
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
CPS?-9 Rev.7/95
STATE OF CONNECTICUT Do NOT fill 1n
DEPARTMENT OF CONSUMER PROTECTION STATE WELL N0.
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING COP nr,IPTT?GN REPORT OTHER NO.
165 Capitol Avenue,Hartf. Connecticut oel o6
OWNER NAME
ADDRESS
A 7
'10 GIRQEJ s"' P?I ? t 77ReBROAD—ROOKs �'
LOCATION (No.8 Street) (Town) 3
OF WELL 700 BUI�L�I�I#�M S s. o. WINDSOR (Lot Number)
DOMESTIC BUSINESS FARM
PROPOSED Li ESTABLISHMENT TEST
USE OF WELL WELL
ElPUBLIC Q INDUSTRIAL
SUPPLY � AIR � OTHER
DRILLING ® ROTARY CONDITIONING (Specify)
COMPRESSED ' CABLE EQUIPMENT � AIR PERCUSSION1:1 PERCUSSIONEl OTHER
(Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT
DETAILS El
DRIVE SHOE�?0 6 1 cr f. THREADED WELDED WAS CASING GROUTED?
YIELD TEST SAILED Q PUMPED COMPRESSED AIR HOURS O'YES NO. YES NO
ie 4 YIELD(GPM)
WATER MEASURE FROM LAND SURFACE-STATIC(Spec fy feet) DURING YIELD TEST(feel) 20
LEVEL 20 325 Depth of Ca..leer Well in feet
MAKE
SCREEN LENGTH OPEN TO AQUIFER(feeQ
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL
Diameter of well GRAVE feet
PACKED: L SIZE(inches) FROM including gravel pack (feet) TO(feet)
DEPTH FROM LAND TO SURFACE (Inches)
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
50 BAWD & GRAVEL
5 325 LEDGEggqq
'tO 4
Sewer' -
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
13ff11'utr11'�d
DATE WELL COMPLETED PERMIT N0. REGISTRATION N0.
f 9/05
DATE OF REPORT LL D L (Signature)