HomeMy WebLinkAboutWell New 72 Maskel Road CONSUMER PROTECTION
WELL DRILLING BOARD srATE OF(ONNECTICUT PERMIT NUMBER
CPR-a REv.,,-,12 DEPARTMENT OF CtSIVSUM@R PROTECTION 87461
WELL DRILLING PERMIT _-
165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106
South W,i.n&on maake£ Road... C
LOCATION OF WELL Mo") (Street) (Lot Nu-ber) - DATE
4-20-84
OWNER OF WELL `
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
40 Shdton Ave., (Vat Haf tjoAd,Ct.
PROPOSED I _-1 DOMESTIC BUSINM MT Est.No.of
❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF'
served.
THER
WELL ❑ SUBLIC AIR UPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ ((Specify) 4
SKETCH OF WELL LOCATION
Locate well with respeci 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(if present)
Indicate North
S /
Approximate number of feet from w t
nearest source of possible contamination:
,001
The undersigned is aware that upon completion .of the well. a 'Well Completion Report" .contoining 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.T is permit is not valid until oil information is filled in and it has been counter-signed by the Director of Health or his agent.
APPIt Sigxat APPLICANT'S ADDRESS REGISTRATION NO.
P-0.8ox 109-38t He-Mon Ave Mutonbuty.Ct f0
BY(lowx Health Officer or A ent) DATE
A ROVED ❑REJE D A" e
u/,2 S—S
RE S
tt'w l°a G
y—a y—rrY
RETURN THIS COPY TO CONNECTICUT WELL-DRILLING BOARD
WELL COMPLETION REPORT :r --
STATE OF CONNECTICUT.
cPR-seEv.,,_sz DEPARTMENT OF CONSUMER;'PROTECTION Do NOT`fiil in
WELL DRILLING BOARD sTprE wEu No.
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME
OWNER ADDRESS
LOCATION (No. 8 Street) � s
(Town) (Lot Number)
OF WELL M"ift Road
PROPOSED DOMESTIC BUSINESS
ESTABLISHMENT
USE OF FARM TEST WELL
PUBLIC
WELL SUPPLY AIR INDUSTRIAL CONDITIONING r (Specify)
j y)
DRILLING COMPRESSED a CABLE II�— OTHER
EQUIPMENT ROTARY AIR PERCUSSION PERCUSSION
(Specify)
LENGTH feet VE HO
CASING (feet) DIAMETER(inches} WEIGHT PER FOOT .WAS CASWG GROUTED?
DETAILSig #erg:. 11 THREADED WELDED YES NO YES NO
YIELD V �! L HOURS
TEST BAILED PUMPED COMPRESSED AIR YIELD(G.P.M.)
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)
LEVEL : Depth of Completed Well
in feet below Land surface: h
MAKE 200
0
SCREEN
LENGTH OPEN TO AQUIFER(feet)
';"
DETAILS SLOT SIZE DIAMETER (inches)
IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feet
PACKED: gravel pack(inches):
DEPTH FROM LAND;SURFACE -'
"FEET TO FEET FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
two Permanent landmarks.
-sand a 1-.
12 N
20 200
go
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT
WELL DRILLER(Signature)
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