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WELL COMPLETION REPORT STATE OF CONNECTICUT _
WDB-5 12-69 REV.vat WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115
OTHER NO.
OWNER NAME ADDRESS
LOCATION (No.&St � � SOR CT.
reet) S. �
OF WELL { # St Crown) (Lot Number)
IM a3 i SOUTH WIr� O
DOMESTICBUSINESS 3
❑ ESTABLISHMENT ❑ FARM
PROPOSEDlki
USE OF El TEST WELL
PUBLIC
WELL ❑ SUPPLY ❑ INDUSTRIAL
AIR ❑❑ OTHER CONDITIONING (Specify)
DRILLING ROTARY ❑ COMPRESSED El PERCUSSION
El (Specify)
EQUIPMENT AIR PERCUSSION PERCUSSION
CASING LENGTH (feet) I DIAMETER(inches) WEIGHT PER FOOT (Specify)
DETAILS 21 I lid THREADED ❑ WELDED DYES OE WAS CASING GROUTED?
'1 a45 1
YIELD I ❑NO CAS NO
HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED F:4 COMPRESSED AIR I 4 WATER �0
MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet)
LEVEL I Depth of Completed Well
in feet below Land surface: 1 ttpt
MAKE .f. 0
SCREEN LENGTH OPEN TO AQUIFER(feet)
DETAILS SLOT SIZE DIAMETER(inches)
IF GRAVEL I Diameter of well including (GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED: gravel pack(inches):
DEPTH FROM LAND SURFACE
FEET to FEET FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
two permanent landmarks.
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If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
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DATE WELL COMPLETED PERMIT NO. I REGISTRATION NO. DATE OF REPORT
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DEPT. OF ENVIRONMENTAL PROTECTION-WATER RESOURCES