HomeMy WebLinkAboutWell New 682 Main Street CONSUMER PROTECTION
WELL DRILLING BOARD STATE OF CONNECTICUT PERMITNUMBER
u cpl a I: v. *ez DEPARTMENT OF CONSUMER PROTECTION 136692
WELL DRILLING PERMIT
`.O ^ ,,,� 165 CAPITOL AVE.,HARTFORD,CONNECTICUT 06106
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LOCATON OF WELL(Town)- (Street) (Lot Nvasber) DATE
R OF WELL �
IINDMDUAL ❑ WILDER OTHER(Specify) 5 ///J�(�!� oe( 40
S
PROPOSED- BUSINESS TEST Est.No.of
DOMESTIC ❑ �TARLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ SU PUBLIC Alit OTHER
Q INDUSTRIAL ❑ CONDITIONING (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roods,showing distance from intersection and irons of lot
Location of lol to at least two foods Well location on lot and to house (if present
9
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Approximate number of feet from well to Q
nearest source Of possible contamination: '
The undersigned is aware that upon completion of the well, o "Well Completion Report" containing construction details and information required under Section
25.131 of the 1969 Supplement to the Gene, I Statutes must be sent to the owner, the Board and The Water u es Commission on the form provided by the
Board.This per is yd' of - for s'fit nd' ho ou b it fw of He s agent.
(Si yre) c � I A ESS � /7 � REGISTRATION NO.
(` O
BY(Tama Health Officer or Ageet) DATE
APPROVED REJECTED
REMARKS
�•�l= c�-7� l.636 3
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
I WELL COMPLETION REPORT STATE OF CONNECTICUT'
CPRAREV.tl.� M DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in
�....t ,m STATE WELL NO.
WELL DRILLING BOARD
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME ADDRESSOWm
'
Daniel R. Shaffer . 682 Main Street, So. Windsor, C`.L' 06074
LOCAl10N (No.&Stieet) (Town) (lot Number)
OF WILL 682 Main Street. So. Windsor..
BUSINIESS
FROPOS@ 9 DOMESTIC 0 ESTABLISHMENT FARM: TEST WELL
IRE OF PUBLIC
INDUSTRIAL CIOt�ITIONING (OSPeCRY)
EQIpFMENT CABLE (ROTARY AIR PERCUSSION El(speci
fy)
y)
CASING LENGTH(Shot) DIAMETER(inches) WEIGHT PER FOOT IVE SK
(wars cAsiNG T D?
210 6 17.4.5 THREADED EI WELDED - YES -. NO O YES NO
HOURS: YIELD (G.P.M.)_
YIBD LI
TEST BAILED a PUMPED COMPRESSED AIR 14
WATER MEASURE FROM,LAND SURFACE—STATIC(Specify 777349
LD TEST(feet) Depth of Completed Well
LEM !3 in feet below Land surface: 150
MAKE LENGTH OPEN TO AQUIFER(feet).
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM (feet) SO(feet-
• -
PACKED:' gravel pack(inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch eitact location of well with distances, to at least
FEET TO FEET two pe
rmanent landmarks.
7,05 i1.S (�•�'t�
Sands-tone /� 1
If yield was tested to different depths during drilling,list below
. FEET GALLONS PER MINUTE Q`i
DALE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPCIRT WE ILDRILLER(Signature) i2xI1 Vril
6-2=83
BOARD.