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WELL DRILLING BOARD STATE OF CONNECnCUT PERMIT NUMBER
wDB a 1169 WEU DRII N— W PERMIT 4 2 6 4 2-
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (Town) (Street) (Lot Number) I DATE 1
SOUTH WINDSOR ROSEMARY LANE 9 9/26/77
OWNER OF WELL
❑ INDIVIDUAL �x BUILDER ❑ OTHER(Specify) RICHARD S. KELLEY
OWNER'S ADDRESS
49 ROSEMARY LANE, S. WINDSOR, CONN.
PROPOSE ® DOMESTIC ❑ BUSINESS
ESTABLISHMENT '� ❑ FARM ❑ VAU Pop!being
USE OF served.
WELL PUBLIC ElR OTHEIt
SUPPLY ❑ INDUSTRIAL ElCIONDMIDNING ❑ (Specify) 4
SKETCH OF WELL LOCATION
Locate well with reaped 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)
Indicate North
Approximate number of feet from well to
nearest source of possible contamination: Sanitary. Sewers
I
The undersigned is aware that upon completion of the well,a"Well Completion Report'containing constructiondetails and information required under Section
25.131 of the 1969 Supplement to the General Statutes must be sent to the owner,the Board and the Water Resources Commission on the form provided by the
Board.-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.
W uro APPLICANT'S ADDRESS REGISTRATION NO. ^g,
LAKE .ST. , VERNON, CONN. 100
� .Q
Y(Town Health Oflame+' dY
end DATE �)Qt'
APPROVED El REJECTED �'
RETURN THIS COPY TO' CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-S 12-69 REV.9-71 WELL DiYiLLINdBOARD•• Do NOT fill in -•
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 0611S
OTHER NO.
NAME ADDRESS
OWNER RICHARD S.. KF.LLEY I 49 ROSEMARY LANE, S.. .WINDSOR, CONK.
LOCATION (No.&Street) (Town) (Lot Number)
OF WELL ROSEMARY LANE SOUTH WINDSOR 9
BUSINESS
PROPOSED ® DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING ® ROTARY ❑ q R PERCUSSION ❑ PERCUSSION ❑ (sCOMPRESSED CABLE - OTHER
pecify)
pecify)
CASILENGTH(feet) I DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS 41_ 6 I 19.45 I ❑ WELDED I THREADED R]YES ❑NO ❑X YES ❑NO -
HOURS YIELD(G.P.M.)
YIELD TEST El BAILED ❑ PUMPED ® COMPRESSED AIR 5 10
WATER MEASURE FROM LAND SURFACE—STATIC(Specify fee:) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 10 I 125 I in feet below Land surface: 1?5
MAKE - I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL I Diameter of well including (GRAVEL.SIZE(inches)FROM(feet) 1TO(feet)
PACKED: gravel pack(inches):
DEPTH FROM LAND SURFACI
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET- to FEET two permanent landmarks.
0 6 Sand & Gravel
6 11 Clay
11 1?5 Bedrock (�
flausE_
If yield was tested at different depths during drilling,list below J
FEET GALLONS PER MINUTE V!h
DATE_WELL COMPLETED PERMIT-NO. !!REGISTRATION NO., DATE OF REPORT'
I WELj„OBILLE (Sign Lure)
10/_29/77- 42642I 10 1 �,�`/
BOARD