HomeMy WebLinkAboutWell New 105 Ident Road WELL 15RILUNG BOARD STATE OF CONNECTICUT PERMIT NUMBER
1NO 11-6' WELL DRILLING PERMIT 7930
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S FICE BUILDING,HARTFORD,CONNECTICUT 06115
4u i N I MbSa A ZE N T I�Ra090 Lo'f
LOCATION OF WELL(Town) (Street) (Lot Number) DATcE�
8 0 1 L►O e n •--�✓l 02 _ a 7Ce�
OWNER OF WELL
❑INDMDUAL BUILDER ❑ OTHER(Specify)
OWNEIVS ADDRESS u�l .~ `? lvt rDSo� Luc-K C6 nt l� -
PROPOSED DOMESTIC ❑ BUSINESS ❑ TEST Est.No.of
USE OF 0 ESTABLISHMENT FARM ❑ WELL People being
served.
PUBLIC AIR
WELL ❑ HER
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (SSppecify)
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)
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Indicate North -
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t
STAttty,
a
3d'
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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 6 of
Public AN 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 informa-
tion is filled in and it has been counter-i n b the Director of Health or his agent.
APPUCANT Sigeoture) `'. ,,// APPLICANT'S•ADDRESS REGISTRATION NO.
A GL• / N -wLx�'KA� I 2 5 � Q,D S �o �° »fel dOw L .41S5. R O
BY(Town WaM Officer or Agent) DATE
APPROVED ❑ REJECTED 7
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-5 12-69 WELL GRILLING BOARD D NOT fill in
STATE WELL L NO.
State Office Building
HARTFORD,CONNECTICUT 06115 �w
OTHER NO.
NAME ADDRESS
OWNER
P t.. 50D 6Z LL
(No. &Street) (Town) (Lot Number)
OF WELL .I I% eo a c:,-L..,'" 1i f m 0 S6 sD�v>
BUSINESS
PROPOSED
U DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE
WELLL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING ❑ COMPRESSED ❑ CABLE ❑ OTHER
EQUIPMENT ROTARY AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT may, DRIVE SHOE WAS CASING GROUTED?
DETAILS ) C/ I It THREADED ElWELDED I!J YES ❑NO ElYES ❑NO
YIELD HOURS G.P.M. } YIELD(G.P.Mj
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)
WATER a Depth of Completed Well j. t
LEVEL . `f in feet below Land surface: J
MAKE 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 Sketch exact location of well with distances, to at least.
FORMATION DESCRIPTION
FEET to FEET two permanent landmarks.
C> t
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE C REPORT WELL DRILLER(Signature) LV
-� - c g CONNECTICUT VAL Y AR EMAN W'ELL CO,JN r