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'E PERMIT NUMBER
STATE OF CONNECTICUT 211695
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL (Town) (Street) (tot Number) DATE
S.WINDSOR 460 MILLER RD. 2/25/02
OWNER OF WELL
12. INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PAGANELLI CONST. — P.O. BOX 652r S.WINDSOR
PROPOSED X DOMESTIC BUSINESS FARM TEST Est.No.of
People being
USE OF ESTABLISHMENT WELL Served.
WELL
SUPPLY ❑ INDUSTRIAL AIR OTHER CONDITIONING (Specify) 4
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 to and to house(if resent)
Indicate North-
• SToN Lr�l��
T1t;
Approximate number of feet from well to ABANDONMENT
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-Department of Consumer Protection and the Water
Resources Commission on the form provided by the agency.-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.
PPLICA T(SignALMV APPLICANT'S ADDRESS REGISTRATION NO.
P.O. BOX 406, WILLINGTON, CT. 42
BY(Town Health OlficerorAgent) DATE
1PPROVED ❑ REJECTED ^L_j r !x Z
REMARKS
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
1
CPR-9 Rev.7/95 - ► R
_ Do NOT fill in
9STATE OF CONNECTICUT STATE WELL NO,
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Adenue,Hartford,Connecticut 06106
OWNER. NAME ADDRESS
PAGANELLI CONST. P.O. BOX 652, SUFFIELD
LOCATION (NO.s Sneer) (Town) (Lof[Number)
OF WELL 460 MILLER RD. S.WINDSOR
DOMESTIC BUSINESS FARM TEST
PROPOSED El ESTABLISHMENT WELL
USE OF WELL PUBLIC INDUSTRIAL AIR OTHER
❑X ABANDONMENT
- SUPPLY CONDITIONING -
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT AIR PERCUSSION 1:1PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(kW*s) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS THREADEDEl WELDED
❑ YES ❑ NO. ❑ YES ❑ NO
YIELD TEST BAILED PUMPED a COMPRESSED AIR HOURS YIELD(GPM)
El El
WATER MEASURE FROM LAND.SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of completed Well in feet
LEVEL 80
MAKE LENGTH OPEN TO AQUIFER(feel)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED: including gravel pad(
(inches)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
0 80 CEMENTED
30 !l
If yield was tested at different depths during drilling,list below rn („LCP Pip
-
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT ILLER(Signature)
2/27/02 211695 42 5/20/02
AGENCY