HomeMy WebLinkAboutWell New 360 Foster Street ZWELI;,..DRI> 1 BOARD STATE OF CONNECTICUT
PERMIT NUMBER
WD34 116 WELL DRILLING PERMIT Z O O Jc-
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (Town) ($treat) (Lot Number) DATE
OWNER OF WELL /
❑ INDIVIDUAL ❑ BUILDER �THER(specify) SevC M F 4 k'y
!/e el. S c
OWNER'S ADDRESS
/PN iS P �S O+v P ro�6
PROPOSED BUSINESS TEST Est.No.of
❑ DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ rye People being
USE OF served.
WELL PUBLIC El SU OTHER PPLYElINDUSTRIAL ❑ CTONDITIONING El (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 Of present)
0
Indicate North
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AD 0 teA
/(o
9a i
� weir
Pea
S3,
Approximate numberlof 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
2—&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.
APPLI Sighature) I APPLICANT'S ADDRESS
/ 1 REGISi TION NO.
r ua �M 5
B own H JJker or Agent DATE)
APPROVED ❑ REJECTED I ,� xb��
REMARKS ��w^�
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
YVELk{OMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in
WDS-5 12-69 REV.9.71 WELL DRILLING BOARD STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
OWNER NAME J �� / I FR ��d (/�rJy/i3 C .()0 J '� ON e.
LOCATION (N 8�, reet) ^ (T ) (Lott Number)
OF WELL (�} d di l�! A// ��f� fi✓(�/ ro
❑ FARM❑ ESTABLISHMENT ❑
BUSINESS
PROPOSED DOMESTIC ❑ TEST WELL
USE OF PPLY 1-1 INDUSTRIAL
WELL II �� UBLIC AIR OTHER
❑ CONDITIONING ❑ (Specify)
DRILLING PRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY AIR MPERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS I ` 117 I -THREADED ❑ WELDED I AYES ❑NO []'YES �NO
HOURS YIELD(G.PM.)
YIELD ❑TEST BAILED 1-1 PUMPED COMPRESSED AIR
/ 1 ii/,
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) �yD r�
WATER ( Depth of Completed Well LEVEL in feet below Land surface: .3�
MAKE I LENGTH OPEN TO AQUIFER(feet) -
SCREEN
DETAILS SLOT SIZE ( DIAMETER(inches) IF GRAVEL 1 Diameter of well including I GRAVEL SIZE(inches)FROM(feet) ITO(feet)
'PACKED: I gravel pack(inches):
DEPTH FROM LAND SURFAC FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks,
D �o� CIA
f-vj
fzti 1
ale
If yield was tested at different depths during drilling,list below a
FEET GALLONS PER MINUTE /�DttPD%•
60
DATE WELL COMP ETED PERMIT NO. REGISTRATION NO. DATE OF EP T WEL RILLER(Signature
3 a o r
BOARD