HomeMy WebLinkAboutWell New 100 Long Hill Road WELL COMPLETION REPORT STATE OF CONNECTICUT Do NOT fill in
CPR-9 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION - STATE WELL NO.
WELL DRILLING BOARD
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
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NAME s. tt ADDRESS �1 t� t
OWNER Clester tubmic i lw tmg 1 i ftady SoNfa 1wtlCt.
LOCATION (No.& Street) r' . (Town) (Lot Number)
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OF WELL to" Ri t7 R"d So. vi1�1r l00
PROPOSED ® DOMESTIC E TSABLI HMENT FARM El TEST WELL
USE OF
WELL SUOTHER
PPLY INDUSTRIAL CIONDITIONING D(Specify)
DRILLING EQUIPMENT ROTARY ® AIRM PERCUSSION El CABLE OTHER
(specify)
CASING LENGTH
t(ff eet) DIAMETER
(inches) WEIGHT PER FOOTO WAS CASING GROUTED?
DETAILS so p mbs ❑THREADED 1� WELDED YES Lj NO ❑YES NO
YIELD HOURS YIELD(G.P.M.)
TEST BAILED +,_ PUMPED COMPRESSED AIR 12
WATER. MEASURE FROM LSiURFACE—STATIC(Specify feet) I DURING YIELD TEST(feet) Depth of Completed Well
LEVEL in feet below Land surface:
LENGTH OPEN TO AQUIFER(feet)
a
SCREEN_
DETA I (inches) IF GRAVEL Diameter of well incf I luding GRAVEL SIZE(inches) FROM(feet) TO(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.
4 42 914 Z gravel
42 54 9ranit8
5Q 200 granite
If yield was tested at different depths during drilling,-list below
FEET GALLONS PER MINUTE
11✓ .
y.
` ATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLF2(Signature)
r
CONSUMER PROTECTION
WELL DRILLING BOARD STATE OF CONNECTICUT ` PERMIT NUMBER
CPih=a IRLW.4-82 DEPARTMENT OF CONSUMER PROTECTION 87477
_
WELL`DRILLING PERMIT _
165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106
LOCATION OF WELL(I ) (Scott) (Lot Numbtr) DA
OWNER WELL
INDIVIDUAL 11 BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED INESS TEST Est.No.of
DOMESTIC ESTABLISHMENT FAR WELL People being
USE OF 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)
Indicate North
Approximate number of feet from well to �� OF
nearest source of possible coniominotion:
The undersigned is owore that upon-completion of the well, a "Well Completion Report" .containing construction details and information required under'Section
25-131 of the 1969 Supplement to the-General Statutes must be sent to the owner. the Board and the Water Resources Commission on the form provided by.the
B .This permit is not valid until all information is fill and it has been countersigned by the Director of Health or his agent.
71
LI (Si lure) APPLICANT'S ADDRESS REGISTRATION NO.
BY(Town Hedth OOker or Agetst) DATE
APPROVED REJECTED — 3'•—S^�/
REMARKS4-1
ipl?00' ioo
RETURN THIS COPY TO CONNECT ICU i WELL DRILLING BOARD
WELL COMPLETION REPORT STATE,OF CONINECTICUT CPR-9 REV.11_82 DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in
STATE WELL NO.
WELL DRILLING BOARD
165-CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
ter.
NAME ADDRESS
OWNER Chester Lubow ckt 100 Long.V111 Road, SoMndsor,Ct.
LOCATION (No. &Street) (Town) (Lot Number)
OF WELL Long Rill Road Se. Windsor i0o
BUSINESS
PROPOSED DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF,•
PUBLIC AIR Fl
THER
WELL SUPPLY INDUSTRIAL CONDITIONING (Specify)
DRILLINGDRILLING COMPRESSED CABLE OTHER
EQUIPMENT ROTARY AIR PERCUSSION ❑ PERCUSSION (Specify)
CASING LENGTH(feet) TER (inches) WEIGHT:PER FOOT �RIV H WAS CASING GRO ED?
176
DETAILS 50 17#'Ibs THREADED WELDED YES NO YES NO
YIELD HOURS /c YIELD (G.P.M.)
TEST I—I BAILED PUMPED COMPRESSED AIR 1 2
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 2f in feet below Land surface: 200
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 FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET TO FEET two permanent landmarks.
0 42 said i~ gravel
42 50 granite
50 200 gran i to
d
If yield was tested at different depths during drilling, list below _
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRIL ER (Signature)
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