HomeMy WebLinkAboutWell New 1609 Main Street WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
1NDB`° 11-6f- = WELL DRILLING PERMIT . 1
260.51,
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
t •d e
LOCATI LL (TosVn)f1r ) (L Number) DATE '
OWMR OFWELE'
10 INDIVIDUALS . ❑ BUILDER ❑ OTHER(5peeify)
OWNER'S ADDRESS
PROPOSEDDOMESTIC ❑ TEST Est.No.oF
ESTABLISHMENT ❑ EARM ❑ WELL People being
BUSINESS
USE OF
served.
WELL ❑ SUPPER
LY
❑ INDUSTRIAL ❑ C,ONDRIONING ❑ (specify) 'rr
SKETCH OF WELL LOCATION
Locate well with respect to at least two roeds,showing distance from intersection and from of lot
-Location of lot to at least two roads Well location on lot and to house Cd present)
. s
Indicate North
.......
I�07
w
e '
Approximate number of feet fidmrl4ill to
nearest source of possible contamination:
The undersigned Is aware that upon completion of the well,a"Well pletion Report" ning construction details and information required under Section
25-131 of the 1969 Supplement to the Ge I'Statutes must be sent to the owner,the Boar nd the Water Resources Commission on'the form provided by the
Boa is rsol v i until I[ of anon is filled in It as been ow rsig y the Director of Health or his agent
we-
A L ) I APPLICANT'S AvoRm REGISTRATION NO.
0.
18y orou SeaJthYffoor or A4aj
I DATE
APPROVED ❑ REJECTED
REMARKS No
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
1 . STATE f coNEuWELLCOMPLEIO REPORT _
"WDB5�12-69 REV.9-71 WELL DRILLING BOARD Do NOT fill itl :. •: ''
State Office.Building STATE'WELL NO;
HARTFORD,CONNECTICU_T 06115 _
_ OTHER-NO,
OWNER N ADDRESS
LOCATION (N e e '& f IT )' y -(Lot Number)
OF•Wdl.
> t.• ' BUSINESS ::..
- PROPOSEDDOMESTIC ESTABLISHME T..". ❑ FARM. ❑ TEST WELL
PUBLIC ' AIR
WELL ❑ SUPOTHER
PLY.'. ❑.INDUST111A1. ":' ❑ CONDITIONING`.' ❑ (Specify)'':. ;
i.-DRILLING• ❑:ROTARY: {{��yy COMPRESSED' CABLE'-., OTHER- '
ECUIPMENi, IR PERCUSSION ...PERCUSSION - ❑ (Specify)
CASING LENGTH(feet)` DIAMETER(inches), WEIGHT PER FOO DRIVE SHOE 'f:WAS CASING GROUTED?
DETAILS' D" .:I=' t C -�: _ _ THREADED � 1NELDMJ .YES' .❑NO ,❑YES"
�.� YIELD'G.P:M.)�
PU COMPRESSE
• .YIELD. '. ;:' �:: ( : :•-. '
e : TEST •❑,BAILED``- ` -'•,❑, MPED•.;' - DAIR
j� - '-• •''
MEASURE FROM LAND SURFACE=STATIC:(Specify feet) DURING YIELD,TEST(feet)"
WATER Depth of Completed Well
I I in feef`be(ow'Land surface /J��:Q• t
'M
AKE'.. e F
'�- � .5_ ... LENGTH OPEENN T TO AQUIFER(feet)
, •.SCREEN`'. "i: �s• :� - ,:4' _DETAILS' SLOT.SIZE. _ DIAMETER(ind�es).' IF:GRAVEL GRAVEL SIZE_(inches)'FROMy(feet)';• •TO(feet),' 4
` Diatneter'of.well•including' _..
PACKED:• I; ".gFavel",pack'•`pnchesk•. G I s =e s'
��,�.•
DEPTHI`ROM`LANDSURFAC -�: Sketch exact_location of well:with di'stana ,ao,aT least,
t FEET ro''FEET. �RMATION•DESCRIPTION'
s• ; . _ rivo•pemtanent;landmarks.
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ry
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gI ywfj.,w4testeif:aT:different'deptlisduriritl'oiilling,.rst.beldw._ - Y • 'S';:'
`t FEET `GAl PER AhINUTE'
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DA7E'WELL COMPLETED [PERMIT'NO:,,%,"1, .REGISTRA ON NO. . PAT OF REPORT-' WE twe) Gt
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