HomeMy WebLinkAboutWell New 119 Ident Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB4 1
'-6' WELL DRILLING PERMIT
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 9 314 -
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LOCATION OF WELL(Town) (Street) (Lot Number) DATE
OWNER OF WEM
.❑INDP✓IDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
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PROPOSED �DOMBi1C ❑ BUSINESS ❑ TEST Est.No.of
USE OF ESTABGSHMENT FARM ❑ WELL People being
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)
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Indicate North I
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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 requi'red under Section 6 of.
Public Act 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-
8on is filled in and if has been counter-signed by the Director of Health or his agent.
APPLICANT(Signature) APPLICANT-S ADDRESS
REGISTRATION NO.
CONNECTICUT VALLEY ARMIAR WELL 13 Z SU4Kea S" oJVA crt�gtvot✓
BY(Town Health Officer or Agent) DATE
❑APPROVED ❑ REJECTED
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 S V) Y11F
OTHER NO.
NAME ADDRESS
OWNER �g ( t
y 4 1 10 i:.R.- a+I C �. ��PI 6 r C? 1� C.3 t
LOCATION (No.& Street) (Town) (Lot Plumber)
OF WELL -3.. e. BUSINESS
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PROPOSED &rDOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC ElSUPP Y ❑ INDUSTRIAL AIR OTHER
❑ CONDITIONING ❑ (Specify)
DRILLING ❑ 1-1�EOMPRESSED ❑ CABLE ❑ OTHER
EQUIPMENT ROTARY (�AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT (�_ DRIVE SHOE WAS CASING GROUTED?
DETAILS (� s I t I
j ' I ®'THREADED ❑ WELDED IES ❑NO ❑YES �eNO
YIELD ❑ ❑ PUMPED I HOURS YIELD(G.P�MJ
TEST BAILED 'COMPRESSED AIR C3
MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet)
WATER f I I Depth of Completed Well
LEVEL 0 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 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.
to 3A 1_19?�
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If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DAY)
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DATE WEL COMPLETED I PERMIT NO. Aj REGISTRATION NO. 1°DATE OF REPORT WELL DRILLER (Signor
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DEFT. OF ENVIRONMENTAL PROTECTION