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WELL COMPLETION REPORT STATE OF CONNECTICUT DO NOT fill in
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
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NAME ADDRESS
OWNER TH �A , 1 03 10 LE L CJIRUE E. HARTFORD r Nl�.
LOCATION (No.&Street) (Town) (Lot Number)
OF WELL 1431 MAIN ST. 30UTH tc INDSO
BUSINESS
❑
PROPOSED DOMESTIC ESTABLISHMENT ElFARM TEST WELL
USE OF PUBLIC AIR
WELL ❑ SUPPLY ❑ INDUSTRIAL El CONDITIONING ❑ OTHER
DRI LLING COMPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY ❑ AIR PERCUSSION PERCUSSION ❑ (Specify)
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
CASING I ( a ( 7 THREADED ❑ WELDED I ❑YES NO ❑YES 7 NO
DETAILS 34 32 � 19. ,
HOURS YIELD(G.P.M.)
YIELD TEST BAILED ❑ PUMPED ❑ COMPRESSED AIR I
"
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well
WATER
LEVEL 2O ( I in feet below Land surface:
MAKE (LENGTH OPEN TO AQUIFER(feet)
SCREEN Verd-u e Bronze Scree (Johnson)
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feet)
2 I 5-5/8 I PACKED: I gravel pack(inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances,to at least
FORMATION DESCRIPTION FEET to FEET two permanent landmarks.
0 ToD 0 iill'
1 12 Sand Gravel
rave
4-
+ F,
C3 Ct Aic
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE 6di
DATE WELL COMPLETED PERMIT NO. 1 REGISTRATION NO. DATE OF REPORT. LER Signatu )
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WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD84 11-69 WELL DRILLING"FIERMIT 33738
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL (Town) (Street) (Lot Number)SOUTH WINDSOR . 1430 MffiIR' S * DATE
( 4/15/76
OWNER OF WELL
In INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) THOMASI MC KENNA
OWNER'S ADDRESS
17 CORNED CIRCI,Es E. HARTFORD, CONN.
PROPOSED DOMESTIC ❑ BUSINESS ❑ FARM ❑ TEST
LL People being
ESTABLISHMENT
USE OF served.
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) 5
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(f present)
Indicate North
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/7/0()J'6;L6'
v
x Y"
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�3 0
Approximate number of,feet from well to 85
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
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.
APP T(Si nature) APPLICANT'S ADDRESS REGISTRATION NO.
LAKE ST. , VERNONI CONN.. , 100
own H officer or Ago"') DATE
APPROVED El REJECTED I17 aw., 'Wcox -04
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD