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WELL COMPLETION REPORT STATE OF SMONEOICUr
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
NAME ADDRESS
�s
OWNER E+JS.ila Fmsts ilm I69 AM ROAD WARPING C01M•
LOCATION (No.&Street) (Town) (Lot Number)
OF WELL MAIN S a SOUTH WINDSM
BUSINESS
PROPOSED DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL .
USE OF
WELL PUBLIC AIR
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING El ((Specify)
DRILLING CABLE
EQUIPMENT ® ROTARY ❑ A RMPRESSED PERCUSSION ❑ PERCUSSION ❑ ((Spec fy)
CASING
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT I DRIVE SHOE WAS CASING GROUTED?
DETAILS 108 I 6 I 19s4!i
THREADED ❑ WELDED [JYES ❑NO R YES ❑NO
YIELD ❑ ❑ HOURS YIELD(G.P.M.)
TEST BAILED PUMPED IR COMPRESSED AIR
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)
WATER I I Depth of Completed Well
LEVEL 25 in feet below Land surface:
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE Diameter of well including
I DIAMETER(inches) I IF GRAVEL I (GRAVEL SIZE(inches)(FROM(feet) ITO(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 — Topsoil
34 GraVe1
Hardpan
ga 22 Haddigh Book
! T
If yield was tested at different depths during drilling, list below 1 r
FEET GALLONS PER MINUTE ' 1 �'
� f
DATE WELL COMPLETED PERMIT NO. I REGISTRATION NO. I DATE OF REPORT I WEL Rit (Signat re)
f.
DIRECTOR OF HEALTH
WELL DRILLING BOARD STATE of CQNNECIICUT PERMIT NUMBER
WDB-4 11-69 WELL DRILLING PERMIT 10486
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL(T (Street) (Lot Number). DATE
=1% WIMM11 MAIN STd 5/1/72
OWNER OF WELL
❑ INDIVIDUAL 1i BUILDER ❑ OTHER(Specify) 0
OWNER'S ADDRESS
69 AM ItOADt WAiP G` W V e
BUSINESS TEST Est.No.of
PROPOSED �x�DOMESTIC ❑ ❑ FARM ❑ People being
ESTABLISHMENT WELL p g
USE OF served.
WELL �-PUBLIC AIR❑'SUPPLY El INDUSTRIAL ❑ CONDITIONING ❑ (SpOTHecify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
1 afioo of lot tout Idast two roads r Well location on lot and to house(if present)
Indicate North
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DRtdy
to
t t/
1�
t
x
' /
A.M V. .
Approximate number of feet from well to
nearest source'of possible contamination: Rn
The undersigned is aware 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 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.
APPLIC i ture) APPLICANT'S ADDRESS REGISTRATION NO.
BY(Town a t O • or Ag nt) DATE
APPROVED ❑ REJECTED a
REMARKS
DIRECTOR OF HEALTH