HomeMy WebLinkAboutWell New 64 Lawrence Road 2VELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB4 i'T-69 WELL DRILLING PERMIT 5349
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 /
LOCATION OF EL own) (Street) (Lot Number) DATE
OWNER Of WELL
INDIVIDUAL ❑BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL El SUPPLY INDUSTRIAL ❑ CONDITIONING ❑ (SpHERfy)
SKETCH OF WELL LOCATION 7
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
c
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 Act 659 must be sent to the owner,the Board and the Wdter Res'curies Commission on the form provided by the Board.This permit is not valid until all informa-
Lion is filled in and it has been counter-signed by the DRrec>or of<Health or his agent.
Siggature APP CA ESS REGISTRATION NO.
?%C7*`
or Agent) DATE
Ld aPPRov� ❑ RF�Ecr� 07 ,V7/
REMARKS z V 7"
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
r t
r
WELL COMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in
WDB-5 12-69 WELL DRILLING BOARD
STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
NA4t§ ADDRE
OWNER [/�[/
LOCATION (No.6 Str t) own) (Lot Number)
OF WELL
BUSINESS
PROPOSED DOMESTIC ❑ ESTABL SHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING El ((Specify)
DRILLING COMPRESSED- CABLE OTHER
EQUIPMENT ❑ ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DIVE SHOE WAS CASING ROUTED?
DETAILS 1� / THREADED ❑WELDED MES ❑NO R YES �NO
YIELD HOURS G.P.M. YIELD(G.P.M.)
TEST ❑BAILED ❑ PUMPED V COMPRESSED AIR '
MEASURE FROM LAND SURFACE—STATIC(Specifyfeet) DURING YIELD TEST(test)
WATER Depth of Completed Well
LEVEL l �' in feet below Land surface: 3
MAKE __JLENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(Inches) IF GRAVEL Diameter of well inducting 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
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
e S �
D
If yield was tested at different depths during dulling',list below
FEET "'. `GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DR ER{Slgna re)
BOARD