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CPR-8 Rev.7195 PERMIT NUUMBER
STATEOFCONNECTICUT 2 2 2 4 69
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
m 165 Capitol Avenue, r-tgbrd Co icut 06106
ti� W�ul S 2 O IN
LOCATION OF WELL �(rTiown) (Steed (Lot Numbed DATE/
40
OWNER OF WELL
U INDIVIDUAL BUILDER• OTHER(Specify)
OWNER'S ADDRESS
Est.No.of
PROPOSED• DOMESTIC BUSINESS FARM a TEST People being
USE OF ESTABLISHMENT WELL served.
WELL PUBLIC INDUSTRIAL AIR OTHER
SUPPLY CONDITIONING (S • )
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 to and to house if resent)
Indicate North
r
Approximate number of feet from well to �� 4—
�
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 Department of Consumer Protection and the Water
Resources Commission on Pe form provided by the agency. This permit is not valid until all information is 110001 in and it has been counter-signed by
the rector of Hejkfth or hi nt.
(CANT(Sig re) APP ICANTS ADDR_& REGISTRATION NO.
C4'c A,3 tto 17J
BY(Town Health Officer or Agent) DATE
ROVED ❑ REJECTED
J bj`
REMARKS ,A n !� � /� � Y Z Z 2—
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTHM
.t'',�PR-9 Rev.7/95 y
Do NOT fill in
STATE OF CONNECTICUT STATE WELL NO.
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE dt PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
OWNER NAMEK
ADDRESS
_tia I
LOCATION (w-a Street) (Tam) (LotNum6ed
OF WELL /)
DOMESTIC BUSINESS FARM /TEST
PROPOSED ESTABLISHMENT WELL
USE OF WELL
AIR
SUPLIC ❑ INDUSTRIAL CONDITIONING1:1 (Specify)
OTHER
DRILLING ROTARYPLY COMPRESSED CABLE OTHER
EQUIPMENT Igni AIR PERCUSSION 1:1PERCUSSION 0 (Specify)
CASING LENGTH(feet) DIAMETER(indm) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS /� �� THREADED WELDED
`t.(� � 1 ��• � 14M YES ❑ No• YES ❑ NO
YIELD TEST BAILED [] PUMPED r�A COMPRESSED AIR HOURS YIELD(
WAT13R MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feel) Depth of Completed Well in feet
LEVEL
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(I-) TO(feet)
PACKED: indudw4 grevet pads
(indtes)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
8 0
n ri
t oC J OA AGO
u 6
TL t Uri
7
U �
M yield was tested at differetri depths Wing drilling,list below
FEET GALLONS PER MINUTE
� a
DATE WELL COMPLETED PERMIT N0. REGISTRATION NO. DATE OF REPORT, WELL 0 IS
AGENCY