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HomeMy WebLinkAboutWell New 490 Clark Street kip CkLLk- S+ WELL DRIWNG BOARD sr®OF CON PERMIT-NUMBER vwsa 11-69 WELL DRILLING PERMIT 4 2 6 3 O- r STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 LOCATION OF WELL (Tome) (Street) -- — (Lot Number) DATE k ce iv �?y h •f 4' OWNER OF WELL LJPJ INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) OWNER'S ADDRESS IC t IZI- O Lq44 r✓ 5hA- PROPOSED 15�.pin" C El •BUSINESS ❑ FJ1RM a TEST Est.No.of E M STABLISHME WELL People being USE OF served WELL AM 071M El SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) SKETCH OF WELL LOCATION Lowe 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 lot and to house(f present) • I� ✓. Indicate Northam. lb/1 • v C,/ /< Approximate number of feet from well to nearest source of possible contamination: Cj y S,p�4. 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 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 wunter-signed by the Director of Health or his agent. _APPLICANT(Signature APPLICANT'S ADDRESS REGISTRATION NO. BY 2'omn O or Agray DATE w �� APPROVED ❑ REJECTED ( I REMARKS f-0 �GF.� T IG iv a !% ayes Q�L.I� 1 SISIS�Q6]'o�� _ f1roUS.Q 5'P 7�.e r Sf)Olf1 04e ,�7 ff Rvy C AS% jA°o/v e/pe Ito ITH .L 6q b Pb Jd�.vTs d� RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD WELL COMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in WDS-S 12.69 REV.9-71 WELL DRILLING BOARD STATE WELL NO. • State Office Building HARTFORD,CONNECTICUT 06115 OTHER NO. OWNER NAME RE SS LEON SZYMCZYK V65NORTH KING ST. , SO. WINDSOR CONN. LOCATION (No..&Street) ,(Town) (Lot Number) OF WELL CLARK ST. , SOUTH WINDSOR CONN. PROPOSED © DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL USE WELL WE PUBLIC AIR OTHER ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) DRILLING ® ROTARY ❑ AIR COMPRESSED EQUIPMENT PERCUSSION ❑ PERCUSSION ❑ (Specify) CASING, LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED? DETAILS 160 feet 6 in. I 17 lbsi Q THREADED ❑ WELDEDI ❑YES gNO [] YES [:]NO HOURS YIELD(G.P.M.) YIELD TEST ❑ BAILED •❑ PUMPED n COMPRESSED AIR { 40 gallons WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well LEVEL (- I-in feet below Land surface: 175 feed MAKE LENGTH OPEN TO AQUIFER(feet) SCREEN DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL Diameter of well including GRAVEL SIZE(inches)FROM(feet) �TO(feet) PACKED: gravel pack(inches): DEPTH FROM LAND SURFAC FORMATION DESCRIPTION Sketch exact location of well with distances,to at feast FEET to FEET two permanent landmarks. - 0 150 CLAY 151 175 RED SAND STONE if yield was tested at different depths during'drilling,list below FEET GALLONS PER MINUTE DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. I DATE OF.RIPORT I WELL DRILLER(Signature) 11 1 4263o I 60 BOARD