HomeMy WebLinkAboutWell New 96 Maskel Road (3) WELL COMPLETION RERORT STATE OF CONNECTICUT
WDB-5 12-69 REV.9.71 WELL DRILLING BOARD Do NOT fill in
STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
OWNER NAME J laid ADDRESS
44 11MMY 3 s
LOCATION (No..& Street) .. (Town) 4 (Lot Number)
OF WELL ROAD XWT11 WINDWR 4
BUSINESS
PROPOSED ® DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL ❑ PUBLIC AIR THER
SUPPLY ❑ INDUSTRIAL El CONDITIONING ❑ (Specify)
DRILLING ® ROTARY ❑ MPRESSED CABLE PERCUSSION ❑ PERCUSSION ❑ (Specify)(
THER
EQUIPMENT AR
CASING
LENGTH(feet) I DIAMETER(inches)I WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?DETAILS 2 6 19,45 I ® THREADED ❑ WELDED F91 YES ❑NO ❑YES [ANO
HOURS YIELD(G.P.M.)
YIELD ❑ BAILED ❑ PUMPED ® COMPRESSED AIR ,h
TEST I T
MEASURE FROM LAND SURFACE—STATIC (Specify feet) DURING YIELD TEST(feet)
WATER I 1 - inpth of Completed
feet below Land Well
LEVEL e: 1
7 MAKE I-
DETAILS LENGTH OPEN TO AQUIFER(feet)
SCREEN SLOT SIZE ( DIAMETER(inches) I IF GRAVEL I Diameter of well including.
GRAVEL SIZE(inches) FROM(feet) TO(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.
0 11 mod. & GrAV*1
11 175 Raddish .bask
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If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED I PERMIT NO. I REGISTRATION NO. DATE OF REPORT WELL ILLE Signat e
) t
DIRECTOR OF HEALTH
WELL-DRILLING BOARD STATE OF CONNECTICUT __ PERMIT NUMBER
"wDB-4 -69 WELL DRILLING PERMIT 10961
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
ATE LOCATION OF WELL(Town) `-'T (Sttrelet(Street) p (Lot Number) D / �}n
SOM
SM.
nSOR
OWNER OF WELL
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) JAM IAM
OWNER'S ADDRESS s
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑'WELL People being
USE OF served.
WELL. PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) 5
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(if present)
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Indicate North
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Approximate number of feet from well to
nearest source of possible contamination: 75
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.This
permit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent.
APPLI (Si ature) APPLICANT'S ADDRESS REGISTRATION NO.
B Heat O er Agent DATE
APPROVED ❑ REJECTED 1
REMARKS }}
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DIRECTOR OF HEALTH