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CONSUMER PROTECTION t
WELL DRILLING BOARD STOOF CONNECTICUT I PERMIT NUMBER
CPR-9 REV.-S-". DEPARTMENT OF CONSUMER PROTECTION
WELL DRILLING PERMIT 6 812 3
20 GRAND STREET,HARTFORD.CONNECTICUT 06106
LOCATION OF WELL(Town) (Street) (Lot Number) DATE
SOUTH WINDSOR DIIIING ST. 12/28/81
OWNER OF WELL
❑ INDIVIDUAL ❑ BUILDER ® OTHER(Specify) ITEW CALVARY CI,UR(H dHMPEL
OWNER'S ADDRESS
DEJ`jT NG ST. , S. WINDSOR, CT.
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF
served.
WELL. PUBLIC AIR OTHER
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot - jwELL.
Location of lot to at least two roads Well location-on lot and to house (if pr sent)
o ae�44
FNorhOIndicat
c.�(/j s�
6_W i,-)6 J'T.
Approximate number of feet from well to 751
nearest 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 Board and the Water Resources Commission on the form provided by the
Board.This permit is not valid until oil information is filled in and it has been countersigned by the Director of Health or.his agent.
�SlgffJtq APPLICANPS ADDRESS REGISTRATION NO.
4& P.0. 'BOX 1112 S. WILLINGTON, CT. 100
BY(Town Heokb Officer or Agent) DATE
APPROVED ❑REJECTED
REMARKS / 0,
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT.- - STATE OF CONNECTICUT
CPR-9 REV.9_79 DEPARTMENT CONSUMER PROTECTION Do NOT fill in —
STATE WELL NO.
WELL DRILLING BOARD
20 GRAND STREET
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME - JADD�RESS.
OWNER CALVARY 0MIGH TRAM ETIME ST. S - T
LOCATION (Na.c&Street) (Town) (Lot Number)
OF WELL DRUNG ST. S. -WINDSOR
PROPOSED ❑ DOMESTIC
BUSINESS
❑ ESTABLISHMENT ❑ FARM Cl TEST WELL
USE OF
WELL PUBLIC AIR ' OTHER
La SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑(Specify)
DRILLING EQUIPMENT ® ROTARY ❑ AIR PERCUSSION CABLEESSED OTHER CUSSION ❑ PERCUSSION ❑(Specify)
CASING LENGTH(feet) DIAMETER(inches)- WEIGHT PER FOOT IV n5 CASING GROUTED?
DETAILS. 41 6 19.45 n THREADED ❑ WELDED_ YES. NO YES ❑NO
YIELD HOURS YIELD(G.P.M.)
TES ❑ BAILED ❑PUMPED .50-COMPRESSED AIR 5 �5
WATER MEASURE FROM LAND'SURFACE—STATIC(Specify 7-t) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 30 �50 in feet below Land surface: 175
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN.
DETAILS [-SLOT SIZE DIAMETER(inches) - IF GRAVEL Diameter of well including GRAVEL SIZE.(inches) FROM(feet) TO(feet
PACKED: gravel pock(inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET TO FEET two permanent landmarks.-
0 2 Topsoil 6,
2 11 Sand & Gravel q
11 31 Clay � Tlk-K
31 175 Fled ]dock
If yield w6s tested Ct OiffereAt depths during drilling,list below
FEET GALLONS PER MINUTE
d
f��tit iN G cl'%
DATE WELL COMPLETED PERMIT.NO. REGISTRATION NO. DATE OF REPORT W% R(Signature)
12Z3a 81 11 68123 100 1 4 82
BOARD