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NG BOARD STATE OF CONNECTICUT PERMIT NUMBER
9 WELL DRILLING PERMIT . • 15389
STATE OFFICE BUILDING,HARM11D,CONNE•CTICUT 06115
LOCATION OF WELL(Town) (Sfreetj (Lof Number D TE
OWNER OF WELL
❑INDIVIDUAL Eg-BTILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ PUBLIC AIR SUPPLY ❑ INDUSTRIAL ❑ 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 on lot and to house(if present)
Indicate North
0.7
J9
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.
APPLICANT AFPLI 5 ADDRlF55 . REGISTRATION N .
• BY(Town�tkalrrAr Age LA APPROVED •REJECTED
REMARKS '
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD .
COMPLETION REPORT STAVE OF CONNECTICUT Do NOT fill'in
D" '12-0. REV.9.71 ' WELL DRILLING-BOARD STATE WELL No.
State Office Building- •
HARTFORD,CONNECTICUT 06115
OTHER NO.
N ADDRESS
•OWNERIvy
?p
LOCATION (No tr t) „ (Town) (Lot Number)
OF WELL. "
tk
BUSINESS
ESTIC ESTABLISHMENT ❑ FARM ❑ TEST.WELL
PROPOSED
USE OF AIR
WELL - ❑ SUPPLY ❑ INOUSTRtAIPUBLIC . ❑ CONDITIONING. (SpHER
ecify)
COMPRESSED CABLE . E
IODRILLI ❑ ROTARY ARUSN.. OT
EQUIPMENT (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT ICI DRIVE SHOE . WAS.CASING GROUTED?
DETAILS / I" I• /�'�(�I Le.J"�HREADED�' []"WELDED I EES ❑NO /M"^ ❑NO
YIELD ❑ PUMPED ❑ COMPRESSED AIR I HOURS YIELD
' TEST D
WATER MEASURE'FROM LAND SURFACE—STATIC(Specify feet) .DURING YIELD TEST(feet) Depth of Completed Well
LEVEL ` I � I in feet below land surface: a
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN I:
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 SURFACEFORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
aJ' -Ad
4/0e"
If yield.was tested at different depths during drilling,lisf below .
FEET GALLONS PER MINUTE ;
A.
DATE WELL COMPLETED PERMIT NO.-- REGISTRATI N NO. DATE OF REPORT- WELL DRI (Si fur OF
'BOARD "
L COMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in
B-5 12-69 REV.9-71 WELL DRILLING BOARD
State Office Building
STATE WELL NO.
HARTFORD,,CONNECTICUT 06115 i f
OTHER NO.
NAME`.
OWNER f J ADDRESS f
LOCATION t ^p -� F(NtPt) `l (Town) (Lot Number)
OF WELL /C J";;1
BUSINESS
PROPOSED 4-eOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPPLY ElINDUSTRIAL ElCONDITIONING ❑ ((Spec fy)
COMPRESSED CABLE
DRILLING OTHER
EQUIPMENT El ROTARY ❑ AIR PERCUSSION ION ❑ (Specify)
CASING
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT ( DRIVE SHOE WAS CASING GROUTED?
DETAILS i tJ L THREADED ❑ WELDED �tES ❑NO Y NOES
YIELD HOURS YIELD(G.P.M.)
TEST AILED ❑ 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:
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) IF GRAVEL Diameter of well including I I 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..
r E' fIsfZ iv C
f`Es r
10G1 }
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE Pa
�tJ)vL�Sr�(Ji��C ,
Vfa'
DATE W L C. PLETED PERMIT NO. '- REGISTRATI•N NO. DATE OF EPORT WELL DRIL Sigdatur F lei
i
DEPT. OF, ENVIRONMENTAL PROTECTION
WELL COMPLETION REPORT ITAIE OF CONNECTICUT -
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115
OTHER NO.
NAME ,'" ADDRESS
OWNERd
J
LOCATION ."(No. &$treet) f (Town) (Lot Number)
r�
OF WELL [��: f ,'fl
BUSINESS
PROPOSED 91-DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE L PUBLIC AIR OTHER
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING COMPRESSED OTHER
EQUIPMENT ❑ ROTARY ❑ AIR PERCUSSION CABLE ION ❑ (Specify)
CASING LENGTH (feet)} DIAMETER(inches) WEIGHT PER FOOT (�7( DRIVE SHOE WAS CASING GROUTED?
DETAILS ( I f �Ir ®-THREADED ❑ WELDEDES ❑NO ❑NO
YIELD HOURS YIELD(G.P.M.)
TEST 94-97alLED ❑ PUMPED ❑ COMPRESSED AIR I j
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)
WATER , r p Depth of Completed Well
# I in feet below Land surface: r
LEVEL �,;
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) IF GRAVEL Diameter of well including
I (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.
i{{
Ix
f}
4 � f
a t a
N.
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. y,. REGISTRATION NO. DATE OF REPORT,�t WELL DRILVR(Sigr(atur !
DIRECTOR OF HEALTH
WELL DRILLING BOARD SLATE OF CONNECTICUT PERMIT NUMBER
wus-a 1-69 WELL DRILLING PERMIT 15389
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL(Town) (Street) (Lot Number) DATE
OWNER OF WELL
❑ INDIVIDUAL []t-saILDER ❑ OTHER(Specify)
OWNER'S ADDRESS.
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ PUBLIC AIR OTHER
SUPPLY ❑ INDUSTRIAL ❑ 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 on lot and to house(if present)
t:
Indicate North
i�
yY �'
/7oo
/Z-
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.
APPLICANT( ', fur APPLICANT'S ADDRESS REGISTRATION NO.
BY(o ealth OJIG7 Age DATE
APPROVED ❑ REJECTED
EMARKS
CNEc,tC 23 2 9
DIRECTOR OF HEALTH