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WELL DRILLM BOARD STATE OF CONNECTICLIT PERMIT NUMBER
wDBd "-69 WELL DRILLING.PERMIT 21883
STATE OFFICE BUILDING,fMTFORD,CONNECTICUT 06175
LOCAT�WELL (Town) • � (street) (Lot NxmLer) #DATE
OWNER OF WELL I
IQINDIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED DOMESTIC ❑ BUSINESS TEST Est.No.of
ESTABLISI AIM ❑ FARM ❑ VML People being
USE OF Alit OTHER served.
WELL ❑ SUPPLY ❑ INDUSTRIAL FUUIC ❑ CONDITIONING ❑ (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 an lot and to house(rf present)
-Indicate North (/V
f
ti � •
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
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.
'APPLt (signature) �/1_ /)- �.APPLICANT AD - REGISTRATION NO.
I„fit I/(LQ•L"W'1GN"A'Z e @
Saalth or or.A DATE
APPROVED ' ❑ REJECTED:: I GtAJ 401. 7-57-71-
RENWRICS .
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT DO NOT fill in
WDB-5 12-69 REV. 9-71 WELL DRILLING BOARD
State Office Building
STATE WELL NO.
HARTFORD,CONNECTICUT 06115 5-w Z63
OTHER NO.
NAME } I ADDRESS
.OWNER � TGc$
1
^Y K
LOCATION (No. & Street (Town)
OF WELL (Lot.Number)
I� i
L(r3 ❑ ESTABLISHMENT SHMENT ❑ FARM
BUSINESS
PROPOSED I�'�OMESTIC ❑ TEST-WELL
USE OF
WELL PUBLIC AIR❑ SUPPLY ElINDUSTRIAL ElCONDITIONING ❑ (Specify)
DRILLING ❑ ROTARY COMPRESSED ❑ CABLE ❑ OTHER
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE I WAS CASING GROUTED?
DETAILS I ( t I THREADED ❑ WELDED I YES ❑NO [ �s ❑NO
YIELD HOURS YIELD-(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet] Depth of Completed Well
LEVEL Ll"2 I 30 I in feet below Land surface:
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I Diameter of well including
DIAMETER(inches) I IF GRAVEL I I GRAVEL SIZE(inches}IFROM(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.
A—
� f
)Dt
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
/ 1
' 3
DATE WELL CpMPLETED I PERMIT NO. REGISTRATION NO.� EP DATE OF RORT WWEIe RI bER (Sicynat+7r )
EPT. OF ENVIRONMENTAL PROTECTION ® INATER RESOURCES