HomeMy WebLinkAboutWell New 813 Graham Road VELL DRILLING BOARD STATE OF CONNECTICUT _ PERMIT NUMBER
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wD -a9 WELL DRILLING PERMIT 1 g.1 8 3 5
STATE OFRCE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION Of WEL f own) (St ) (Lot Number) DATE
OWNER Of WELL -
4DIVIDUAL ❑BUILDER ❑OTHER(Specify)
OWNER'S ADDRESS
PROPOSED �'�/DOMEST� BUSINESS TEST Est.No.of
USE OF IJ ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
served.
PUBLIC AIR OTHER
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF.W_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)
irate North
Jr
Approximate number of feet from well to
nearest source of possible contamination:
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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 tohe General Statutes must be sent toant
the Board and the Water Resources Commission on the form provided by the Board.This
permit: not valicuntil all informafion is fitted'in ancl'it has beened b f Health or his agent.
(Signature) APPRESS REGPTRA ON NO.
BY(Town aftb OEFcer w Agent) DATE
❑APPROVE) ❑ REJECTED �.• ��r .��.
IV
REMARKS - .. .� _ ' ��� •
` RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUr Do NOT fill in
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115 (�
OTHER NO.
OWNER NAME tf I ADDRESS
1S - f, z,
LOCATION (No. & Street) (Town) (Lul Number)
OF WELL
BUSINESS
PROPOSED Z DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
AIR
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ ((Spec fy)
DRILLING COMPRESSED CABLE OTHER
EQUIPMENT u ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE" WAS CASING GROUTED?
DETAILS j ( I I THREADED ❑ WEL DED I ❑YES ❑NO ❑YES ❑NO
HOURS YIELD (G.P.M.)
YIELD TEST ❑ BAILED ❑ PUMPED ❑ COMPRESSED AIR Z./
MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet)
WATER MEASURE
of Completed Well
LEVEL I I in feet below Land surface: ��
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including
GRAVEL SIZE(inches)(FROM(feet) TO(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.
43
,;
{
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 DRILLE"Awnature)o
)
1-41
DEPT. OF ENVIRONMENTAL PROTECTION