HomeMy WebLinkAboutWell New 00 Grace Road 7NELL DRILLING BOARD STATE OF CONNECTICUT
' PERMIT NUMBER'
WDB-a 11-69 WELL DRILLING PERMIT i 2 2 6 9
r STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
i
LOCATION OF WELL(Town) (St {Lof Number) DATE
SWTK ;WIND
ROADiilo 9/19/72
OWNER OF WELL if
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) CAnO
OWNER'S ADDRESS
69 ASS I&0", W"PIXI. COM.
PROPOSED BUSINESS TEST Est.No.of
FA DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ PUBLIC AIR SUOTHER
PPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
f -fLocation of lot to at least two Toads r
Y• y Well location on lot antd to house(if pr{sent) t
Indicate North
Al
.>
Au
Approximate number of feet from well to
nearest source of possible contamination.
The undersigned is aware that upon c mplet*on of the well,a"Well Completion Report"containing construction details and information required under Section 25-131
of the 1969 Supplement to the Gen al Str}tutes 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 informatio is f' ed in and it has been counter-signed by the Director of Health or his agent.
O ANT Signatuo APPLICANT'S ADDRESS REGISTRATION NO.
f
BY(Town ea O {cer or gen) DATE
APPROVED REJECTED
REMARKS j
4
DIRECTOR OF HEALTH
{x �� �M��'.t� ... x. -�-? 'J zYz'."' �;.a �,_�''+a`:tea ',YA"k�Ji_ �t 'v.•-, i'K. @flay. �p;�ia�}t �" "��'
0.
WELL COMPLETION REPORT STATE OF CONNECTICUr
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
STATE WELL NO.
t State Office Building
HARTFORD, CONNECTICUT 06115
OTHER NO.
OWNER
NAME ADDRESS ley
O � i0 I 69 20"s "PM9 CM.
LOCATION ss (No. &Street) (Town) (Lot Number)
OF WELL ORM RO I -A SOM W
BUSINESS DOMESTIC ❑ ESTABLISHMENT ❑ FARM
PROPOSED TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
EQUIPMENT ROTARY AIRDRILLING PRESSED CABLE PERCUSSION ❑ PERCUSSION El (OSpec fy)
CASING LENGTH (feet) I DIAMETER(inches)I WEIGHT
PER i DRIVE SHOE WAS CASING GROUTED?
DETAILS i �''7T" THREADED ❑ WELDED I 1!!I YES [:]NO ❑YES ENO
HOURS YIELD(G.P.MJ
YIELD
TEST ❑.BAILED ❑ PUMPED ® COMPRESSED AIR
MEASURE FROM LAND SURFACE-STATIC (Specify feet) DURING YIELD TEST(feet)
WATER Depth of Completed Well
LEVEL I � I in feet below Land surface: 17
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including
GRAVEL SIZE(inches)(FROM(feet) ITO(feet)
PACKED: ( 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.
Q ?� Topsoil
3 38 Grayel
38r 175 Red R"k
C
i
If yield was tested at different depths during drilling,list below 1 `
� .� er
FEET GALLONS PER MINUTE vie t
RI)c r5 11
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. I DATE OF REPORT ,4AWLL PRI EKSignat re)
s
LOCAL DIRECTOR Of HEALTH