HomeMy WebLinkAboutWell New 1562 Main Street WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD&4 11-69 WELL DRILLING PERMIT 2 6 O 4 8-.
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 L„*
LOCATION OF W L (Town) ($tr t) (Lot Number) I DATE
OWNER OF E
INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED ❑ BUSINESS ❑ ❑ TEST Est.No.of
USE OF
DOMESTIC ESTABLISHMENT FARM WELL People being
WELL served
❑ SUPPLY ❑ INDUSTRIAL ❑ CIONDITIONING ❑ (Sp7mecRify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from inter action and front of lot
Location of lot to at least two roads Well I tion on.lot (if present)
Indicate North
` �d!IutiG,
Approximate number;(feet from well to
nearest source of-possible contamination: Itz
The undersigned is aware that upon completion of the well,a'Well-Completion 'containing-construction details and information required under Section
25-131 of the 1969-Sigiplement to the GenerpPSNtutes must be sent to the owner,the Board and the Water Resources Commission on the form provided•by the
Boa is r is valid- all in mat is filled in an bee tounte gned b the Director of Health or his agent.
APPfr,W` {APPLICANT.' REGISTRATION NO.
2T
i. I .
I BY T eatth 0 or ant)' DATE a
APPROVED ❑ RFJECTEO 1
REMARKS
IF
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL•COMPLETION REPORT 'STATE OF CONNEcnCUT'< Do NOT fill in
.._ WELL.DRIL�ING BOARD
WD&5 12d9 REV:9-71 't. ` STATE WELL NO.
State Office Building
HARTFORD,CONNECiIdfi 0¢l.l •S .,
OTHER NO.
OWNER. NAME ADDRESS
•LOCATION o'!L_Street) CT ) (Lot Num r),
OF WELL
DOM . BUSINESS'•
ESTIC <
PROPOSED'. + 'ESTABLISHMENT 0 yFARNI• . ❑ 7EST•Wp L.
USE OF. PUBLIC' _:.:..• a
WELL y AIR'''. OTHER. -
SUPPfY :INDUSTRIAL-:a I ;CONDITIONING. (Specify)
` DRILLING f� COMPRESSED" {—� CABLE , OTHER,,.; P �:
EQUIPMENT t-J ROTARY •' ,AtR PERCUSSION LJ!•RERCUSSION, (Specify)
LENGTH(feet) J DIAMETER-(Inches) 'WEIGHL PER . T :._. DRIVE SHOE- WAS CASING GROUTED?
•S CASING, ` !.
DETAILS ®5 THREi4DED=` ;WELDED I ,YES NO a YES :R NO
HOURS YIELD(G.P.M:)
....TEST
BAILED: a.PIIMFED COMP.RESSED•AIR '.
r. /o
„• DURIN 'YIEDT-(feet)MEASURE'FROM LAND SURFA —5TAT1 "(SpecifyM
WATER ih o;CotnPleted Well
:a'IEVEI. :I. Y :il_In•feet below Land surface:- '
LENGTH OPEN TO AQUIFER(feet)
SCREEN' - �j,••_� '� -,� .. . . •. t r. } • - •. _ :.
:2 DETAILS SLOT\SIZE" DIAMETER(inches);• IF GRAVEL`' .CO(arneter,of well`indudin'' VEL'SIZE{inches)FROM(feet)^ TO(feet)•,
I; I•PACKED• .I: :gravel pack(inches): g y . - I_'
,i'._ _�
DEPTH FROM LAND SURFAC t = SlieTili•exact, iatian of wa ll-wi t
FORMATION DESGRIP.TlON? . . lo h disitarices* it.Iaast i.
' FEET to FEET • ?.= ,Y two-
0permanent.landmarks _
Y
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."i
_ Z.
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.a.. 'tea. _ - _ .'Fr '•�• .4+, �" - ••.+ tom.
•.s
X.
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If=yietd was tested"at different depths_=dwi_ng dril(ing,aist.below
s �FEE"6 - R MINUTE •' t'. •_, •e•'` GALLONS•AE
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-DATE WELL COMPLET_ED,�•: .PERMITf:NO. _ REGISTR O. ATE OF REPORT '� W gnatur
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