HomeMy WebLinkAboutWell New 185 Lake Street WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
"f0� "�9 WELL NILi q, PERMIT11628
STATE OFFICE BUILDING,HAMAD,CONNECTICUT 06115
L OF WE Town) (S t) (Lot Number) DA
OWNER OF WELL
❑INDIVIDUAL 5 BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
Age
PROPOSED BUSINESS TEST Est.No.-of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM WRL People being
USE OF .
served.
PUBLIC Alit OTHER
WELL ❑ SUPPLY El.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
T,e x
I
4� leg e
I ��V
' W
(0A -
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware that upon co le' n.of the well,a"Well Completion Report"containing construction details and information required under Section 25-13.1
of the 1969 Supplement to the Genera S tutes must-be sent to the o , e Board and the Water Resour as Commission on the form provided by the Board.This
perm' ' valid u til all information I. Iled in and it has been-cou r-sig the Di of Health or is agent.
Of!fol
APPLI- (Si ) APPLICA 'S ADD REGISTRATIIOONNO.
l/e
wn Health or Agent) DATE
L�APPRONW ❑ REJECTED O$�O^7 1-
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
e �
WELL COMPLETION REPORT STATE of coNNECTIcuT Do NOT fill in
WDB-5 12-69 REV.9-71 - WELL DRILLING BOARD STATE WELL NO.
State Office Building V, /�[�^�
HARTFORD,CONNECTICUT 06115
OTHER NO.
NAME I ADDRESS
EWTION
NER V gRN I V e I E. Akf 0 � CO:4
(Town) - (Lot Number)
A (No. &Street) s rT�. 0
WELLBUSINESS r'sL 3 .
DOMESTIC, ❑ ESTABLISHMENT ❑ FARM TEST WELL
PROPOSED OTHER
USE
WELL PUBLIC INDUSTRIAL El CONDITIONING ❑ (Specify)
'l ❑
f❑ SUPPLY
COMPRESSED. CABLE OTHER -
DRILLING ❑ ROTARY - ❑ AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
EQUIPMENT DRIVE SHOE WAS CASING GROUTED?
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT CASING I { � I THREADED El HOURS
[YES ❑NO ❑YES $ NO
DETAILS d HOURS YIELD(G.P.M.)
10
YIELD ❑ ElPUMPED � COMPRESSED AIR
TEST BAILED
MEASURE FROM LAND SURFACE—STATIC(Specify feet)I DURING YIELD TEST (feet) I Depth of Completed Well
WATER in feet below Land surface: 5
- I LENGTH OPEN TO AQUIFER(feet)
LEVEL 2
MAKE
SCREEN I GRAVEL SIZE(inches)FROM(feet) ITO(feet)
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL I Diameter of well including
PACKED: gravel pack(inches).
Sketch exact location of well with distances,to at least
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION two permanent landmarks.
FEET to FEET
e is-1 Rock
f
i
t tut
�.
If yield was tested at different depths during drilling, list below £
FEET
GALLONS PER MINUTE ` "
F
i
DATE WELL COMPLETED PERMIT N0. I REGISTRATION NO: I DATE OF REPORT I WEtL R R(Sign ure)
DEPT. OF ENVIRONMENTAL PROTECTION