HomeMy WebLinkAboutWell New 32 Linda Lane eONSUMER PROTECTION 52- W-AA-Q,
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
CPR-$REV 1111.e2 DEPARTMENT OF CONSUMER PROTECTION 154846
WELL DRILLING PERMIT
165 CAPITOL AVE.,ff.ARTFORD,CONNECTICUT 06106
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LOCATION OF WELL(Cowfxi (Street)• (Lot Number) DATE
OWNER OF WELL
11 NdXV DUAL WILDER - OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BLISINEff TEST Est.No.of
ESTABLISHMENT a FARM WELL People being
USE OF . _ served.
AIR
WELL PLISUPPLY Q INDUSTRIAL CONDITIONING OTHER.
SKETCH OF WELL LOCATION
Locale well with respect to of least two roads,showing distance from intersection and front of lot
location of lot to at least two roods Well location on lot and to house (if present)
Ind+aole North
dF
Approximate number-of feet from well to
nearest source of possible contamination: 757
The uitdtnigned is aware that upon completion of the well, o "Well Completion Report" containing construction details and information required under Section
2S-131 of the -1969 Supplement to the General Stotules.must be sent to the owner, the.Board and the Water Resources Commission•on 'Ihe form provided by the
Board.This permit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent.
APPLICANT rro) APPLICANT'S ADDRESS
• � REGISTRATION NO.
BY(Taex Hedtb Ojfrcrr or Agex DATE
REJECTEDEl
REMAKr
2 Rom'
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
, ,•NO
WELL COMPLETION REPORT STATE of CONNECTICUT —CPR-9 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION , Do NOT fill in
WELL DRILLING BOARD ' STATE WELL NO.
165 CAPITOL AVE. _
HARTFORD,CONNECTICUT 06106 OTHER NO.
OWNERNAMEN ADDRESS
IL?GNr✓ Vl�`� / 7`�O e4.4i1Y4roN R13� 6of�rN t�r��spie er- 46o75r
LOCATION (No.B Street) (Town) (Lot Number)
OF WILL 3 41/V t3 i4 1,91116 W/W bBUSINESS
PROPOSED
® DOMESTIC ESTABLISHMENT FARM El TEST WELL
USE OF
PUBLIC
WELL THER
SUPPLY INDUSTRIAL CIONDITIONING ((Specify)
DNILNG UPWANT ® ROTARY ® AIRM COMPRESSED
PERCUSSION PERCUSSION OTHER USSION (
EQ (Specify)
CASING. LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT WAS CASING GROUTED9
THREADED WELDED YES NO YES NO
y1 TEST
® ®COMPRESSED AIR HOURS 1j YIELD (G.P.M.)
TAT BAILED PUMPED T �D
WATEE MEASURE FROM LAND SURFACE—STATfC(Specify feet) pURING YIELD TEST(feet) [Depth of Completed Well
LEVEI .?`3' feet below pond surface: —7..7-57,
MAKE LENGTH OPEN TO AQUIFER (feet)
scum
(inches)
SC GRAVEL SIZE
DETAILS SLOT SIZE grovel IF GRAVEL Diameter of well including (inches) FROM(feet) TO(feet
PACKED: gravv pack pock (inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to of least
FEET TO FEET two permanent landmarks.
T-1
y5 !
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
pNDA 1-fdf`{LG
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature)