HomeMy WebLinkAboutWell New 95 Ident Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD". 11-69 WELL DRILLING PERMIT 9 315
R .
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
3OUIH UJIt (&.7)F417 Ro QI
LOCATION OF WELL(town) (Street) (Lot Number) DATE
A IR V1 gr 12 .`3 •—!
OWNER OF WELL
INDIVIDUAL ❑BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
v rf LJ I ri 10 S 6 a-- L4.1e— Co N I�-1
PROPOSED BUSINESS TEST Est.No.of
USE OF ErDOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
served.
WELL PUBILIC❑ SUPPLY ❑ INDUSTRIAL ❑.CIONDITIONING ❑ STHER
pedW IS—
SKETCH OF WELL LOCATION
Locate well with respect to of 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
• t I
L.. .J
Indicate North
� 1
STAD n of
40'
`R040
Approximate number of feet from well to
nearest Source of possible contamination: �S
The undersigned is aware that upon completion of the well,a"Well Completion Report"containing construction details and information required under Section 6 of
Public Ad 659-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 informo--
tion is filled in and it has been countersigned by the Director of Health or his agent.
APPLICANT(Signature) 4_*_ , w APPLICANT'S ADDRESS �.` ` REGISTRATION NO.
CONNECTICUT VALLEY ARTESIAN WELL M tN '3 Z K�/t 0-1 on ee.�10 Vho
BY(rown Health Officer or Agent) DATE
ElAPPROVED ❑ REJECTED 1 1.11 .
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-5 12.69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
STATE WELL NO.
State Office Building
HARTFORD, CONNECTICUT 06115
OTHER NO.
NAME ADDRESS
OWNER ---1 if�aC
a tom., t yr ea.S'6 K G.
LOCATION (No. & Street)) 14.11
• ] (Town) (Lot Number)
OF WELL if! ^'i*" � t� _�V 1 -7 tJs'fS
BUSINESS
PROPOSED u DOMESTIC El ESTABLISHMENT El ❑ TEST WELL
FARM
USE OF
WELL ❑ PUBLIC AIR OTHER
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
p,=MPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY �]
DRILLING AIR PERCUSSION El PERCUSSION ❑ (Specify) .
LENGTH(feet) DIAMETER(inches)I WEIGHT PER FOOT I DRIVE SHOE WAS CASING GROUTEDCASING
DETAILS t f ,� ErTH'READED ❑ WELDED PI-ES ❑NO ❑YES eNO
YIELD ❑ ❑ 'COMPRESSED AIR HOURS YIELD{G.P.M.1
TEST BAILED PUMPED
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) o Depth of Completed Well /
LEVEL ( J':_`� I in feet below Land surface: ✓ (!!
HAKE 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)
I PACKED: I gravel pack (inches): I
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
�$ C Ld; 1
STo o! Rd.� )
3q t r 14 Er
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 DRILLER(Sign )
i7 ? I G ' Cede ALLEY AR TESIAW WELL-Co, INC
DEPT. OF ENVIRONfikENTAL PROTECTION