HomeMy WebLinkAboutWell New 391 Niederwerfer Road CONSUMER PROTECTION
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
CPR-e REV.11-82 DEPARTMENT OF CONSUMER PROTECTION 142791
WELL DRILLING PERMIT
165&,PITOL MM)E.,HARTFORD,CONNECTICUT 06106
L OF W It(Town) (Street) (Ceti-�Namber) GATE
« t��4ic. w tx� (� " ! a iL
t&OWNER OF WELL �SeF l l
*Wnf DUAL 0 BUILDER OTHER(Specify) Cam'
OWNER'S ADOR
GOle
v�4
BUSINESS TEST Est.No.of
PROPOSED DOMESTIC El ESTABLISHMENT FARM WELL People being
USE OF served.
WELL PUBLIC AIR OTHER
El SUPPLY El 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 roods Well location on lot and to house (if present)
Indicate Worth00 0
0
je
0
3 \
Q �
3
Approximate number of feet from well to 1 Qc)f
nearest source of possible contornination:
The undersigned is aware that upon completion of the well, a "Well Completion Report" containing construction details and informotion required under Section
25-1 1 0 = ment to the general Statutes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the
is it is Olt,
liAniil a i o n is it os been countersigned by the Director of Health or his agent. -
ICANT'S ADDRESS REGIST I
0 3 rrNe.r,Jo�
BY(r'omm Hedrb Officer or Ageer) DATE
APPROVED ❑REJECTED
REMARKS
pca
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL-,COMPLETION REPORT STATE of CONNECTICUT Do NOT fill in
Ck-v REV.11-82 DEPARTMENT OF CONSUMER PROTECTION STATE WELL NO.
WELL DRILLING BOARD
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME ADDRESS
OWNER
LOCATION (NO.8 Street o ri - a+ t NJ berg
OF WALL 391 NTEDERVERFER1 RD. WTIm-mR . M
a BUSINESS
PRO►OSM DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL - -
USE OF
WIL` PUBLIC❑ SUPPLY ❑ INDUSTRIAL ❑ CIONDITIONING ❑((SpecRy)
EQIN►MENT ❑ ROTARY AIR RMPREC SSION ❑D CABLE PERCUSSION ❑((THER
Specify)
LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT wA5 CASING GROUTED?
DETAILS H ry THREADED ❑ WELDED YES NO YES ❑NO
YID
HOURS YIELD (G.P.M.)'
TEST ❑ BAILED ❑ PUMPED a COMPRESSED AIR a
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 70 3241 in feet below land surfoce:.4 ,, t -
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETANS 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 FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET TO FEET two permanent landmarks.
S
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 LL DRILLER{Signature).
`._ 142701 . d4 23 .9 h
DEPT.OF ENVIRONMENTAL PROTECTION-WATER RESOURCES