HomeMy WebLinkAboutWell New 1624 Main Street WELL DRILLING BOARD, STATE OF CONNECTICUT PERMIT NUMBER
wDs4 11 69 WELL DRILLING PERMIT 33881
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 0611S
LOCATION OF,WELL (Town) (Street) (Lot Number) ' DATE
OWNER OF WELL
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) Iv SE'd/�" ~'Al dr. -
OWNER'S ADDRESS
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BUSINESS . TEST Est.No.of
PROPOSED
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF
mod'
WELL PUBLIC AIR OTHER
_ ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
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 Of present)
Indicate North
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Approximate number of feet from well to
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. Thhiis_pe mit Is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent,
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APPLI ) APPPLLICANT'S ADDDRE�SS of I REGISTRATION NO.
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('� y(Tow Ke h 0 or Agent) I DATE
L.J APPROVED' REJECTED ¢I2 9/74 IJ 4
REMARKSTor
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
FELL 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
USGS a COPIES MADE
OTHER NO.
NAME J
ADDRESS
OWNER
LOCATION �a (No.&Street) (Town) (Lot Number)
OF WELL Wjtt
BUSINESS
PROPOSED
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER
!DRILLING �----��,�,,�OMPRESSED CABLE OTHER
EQUIPMENT ❑ ROTARY l AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
CASING t z THREADED ❑ WELDED S ❑NO ES ❑NO
DETAILS � ( I I
HOURS YIELD(G.P.M.)
TI STD ❑ BAILED ❑ PUMPED COMPRESSED AIR
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) I Depth of Completed Well
WATER
LEVEL in feet below Land surface:
MAKE (LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including 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.
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If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
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DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature) t
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