HomeMy WebLinkAboutWell New 376 Deming Street WEL;:..VRIL!;ENG BOARD STATE OF CONNECTiCUT PERMIT NUMBER
wDs•i 1149 WELL DRILLING PERMIT 20021
STATE OfFICE BUILDING,HARTFORD,CONNECitCUT 06115
LOCAT ON Of WELL (Town) (b'tr"O (Lot Xusabsr) DATB
OWNER OF WELL
919011VIDUAL ❑ BUILDER ❑ OTHER(specify)
OWNER`S ADDRE
PROPO M '^^E"'O El BUSINESS
I ❑ F eo a
use OF ESTABLISHMLM ❑ N. Peopbet g
R OTHER ��
WELL ❑ SUPPLY ❑ MUSTRIAL ❑PUBLIC aCONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate 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(if present)
s`s
Icdicata Norilt
3>
%Fo a �
v.
711
ZVI
Approximate number of feet from well to
nearest source of possible contaminations s+
The undersigned is aware that upon.cmnpletion of the well,a'Well Completion Report"containing constitution details and information required under Sefton
25.131 of the 1969 Supplement to the General Statutes must be sent to the owrler,the Board and the Water Resources Commission on the form provided by tha
Board. This permN is not valid unfit all information is filled in and It has been counter•signed by the Director of Health or his agent
APPLICM ( APPLICANT'S ADDRESS +REGISTRATION NO.
w r I
I BY Tow;J1
th or or DATE
APPROVED a RMECTW
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
DELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-5 12-69 REV. 9-71 WELL DRILLING BOARD do NOT fill in
Slate Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115 Vi,J ' j�
OTHER NO.
NAME ADDRESS
OWNER
1 f t eP r tv 2
LOCATION (No.&Street) (Town) (Lot Number)
Of WELL
BUANESS
PROPOSED 2 DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL ❑ PULICSUPPLY' ElAIR INDUSTRIAL INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING OMPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY L3LI AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVES OE WAS C ING GROUTED?
CASING f[� I �HREADED ❑ WELDED YES ❑NO YES ONO
DETAILS ,
YIELD HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR II
MEASURE FROM LAND SURFACE—STATIC (Specify feet) `DURING YIELD TEST(feet)
WATER - Depth of Completed Well
LEVEL I in feet below Land surface: 00
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including
GRAVEL SIZE(inches) FROM(feet) TO(feet)
I PACKED: I gravel pack(inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
a t 190L Y)
or
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
T e t')`1 P1 i 1
DATE WELL COMPLETED `PERMIT NO. i REGISTRATION NO. +DATE OF REPORT WELLDRILLER(Sign ture)
s '1 1,31
}R°PTo OF ENVIRONMENTAL PROTECTION — LATER RESOURCES