HomeMy WebLinkAboutWn New 400 Deming Street WELL DRILLING BOARD WATE"OI&CONNECTICUT PERMIT NUMBER 4
WDB4 11-69 WELL DRILLING PERMIT •
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STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (Town) (street) (Lot Number) DATE
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OWNER OF
EZOWIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS yy7
BUSINESS TEST Est.No.of
PROPOSED
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL PUBLIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER
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)
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Indicate North
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Approximate number of feet from well to Q f3 /
nearest source of possible contamination: f/ V
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 counter-signed by the Director of Health or his agent.
APPLICA ature I APPLICANT'S ADD I REGISTRATION NO.
A
'00,
B (.Town 2tedt O}}dcer e I DATE
&REARKS
PPROVED El REJECTED
DIRECTOR OF HEALTH
WEI
11
F.
Mrk � a -
WELL COMPLETION REPORT sraT;E.O&CONNECTICUr Do NOT fill in*
WDB-5 12-69 REV. 9-71 WELL DRILLING BOARD STATE WELL NO.
State Office Building :
HARTFORD,CONNECTICUT 061IS-
OTHER NO.
NAME ADDRESS
OWNER x.
r
LOCATION (No.&Street) (Town) (Lot Number)_
OF-WELL
BUKNESS
PROPOSED "OMESTIC ElESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF PUBLIC AIR OTHER
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING ryICOMPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY LVJ AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE OE WAS C SING GROUTED?
CASING I �/—' �THREADED ❑ WELDED YES ❑NO YES ❑NO
DETAILS s I 1 I�."Y..S
YIELD
HOURS t YIELD(G.P.M.)TEST El BAILED ❑ PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet)I DURING YIELD TEST(feet) I Depth of Completed Well
LEVEL in feet below Land surface:
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL I Diameter of well including I GRAVEL SIZE(inches)(FROM(feet) ITO(feet)
PACKED: gravel pack(inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances,to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
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If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO, DATE OF REPORT WELL DRILLER(Sig ture)
LOCAL DIRECTOR OF HEALTH