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HomeMy WebLinkAboutWell New 350 Deming Street CONSUMER PROTECTION 3 C�M'I WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER CPR-0 REV.11-82 DEPARTMENT OF CONSUMER PR TECTaION 100199 WELLAbRILLAG PERMIT 165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106 LOCATION OF WELL(Torun) (Sheet) (Lot Number) DATE ld OWNER OF WELL ® INDIVIDUAL BUILDER OTHER(Specify) OWNER'S ADDRESS 1--- � cSv I�n z a - © BUSINESS TEST Esf. No.of PROPOSED DOMESTIC ESTABLISHMENT ❑ FARM WELL People being USE OF served. WELL PUBLIC AIR OTHER a SUPPLY EI INDUSTRIAL CONDITIONING (Spedfy) C SKETCH OF WELL LOCATION Locate well with respect to of least two roads,showing distance from intersection and front of lot Location of lot to of least two roads Well location on(of and to house(if present) G/zll 36 A Indicate North ,0 CIA liq Approximate number of feet from well to � 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 2S-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. APPLICANT(S'nature) APPLICANT'S ADDRESS ) REGISTRATION NO. 17 ❑ BY(Town Health Officer or Agent) D OV APPRED REJECTED REMARKS - -- `AGANETTI__WELL_DRILLING_C0._INC. _ - ROUTE 17 DURHAM,CONN.06422 3Yg RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD WELL COMPLETION REPORT STATE OF CONNECTICUT CPR-9 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in WELL'DRILLING BOARD STATE WELL NO. 165 CAPITOL AVE. HARTFORD,CONNECTICUT 06106 OTHER NO. OWNER NAME ADDRESS LOCATION (No. & Street) (Town) OF WELL j (Lot Number) c3� �1 � 8� 11GLtBUSINESS 4 7} PROPOSED DOMESTIC ESTABLISHMENT HMENT FARM TEST WELL USE OF WELL PUBLIC AIR OTHER SUPPLY INDUSTRIAL CONDITIONING �(Specify) COMPRESSEDDRILLING OTHER EQUIPMENT ROTARY AIR PERCUSSION PERCUSSION (Specify) CASING LENGTH (feet) DIAMETER (inches) WEIGHT PER FOOT IVE HO n5 CASWG GROUTED? DETAILS ,{ THREADED WELDED YES NO YES NO YIELD HOURS YIELD (G.P.M.) TEST BAILED PUMPED 2 COMPRESSED AIR WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well LEVEL in feet below Land surface: 300 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. f PIAle 1 IQnAP If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WEL•COMPLETED PERMIT NO, REGISTRATION NO. DATE OF REPORT WELL RILLER(Sign ture) s DEPT. OF ENVIRONMENTAL. PROTE(_'TI0M—WATI=0 Qr:CnIfor-rac-