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HomeMy WebLinkAboutWell New 446 Niederwerfer Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER WD" 11-69 WELL DRILLING PERMIT 20271 STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 c - P i LOCATION OF WELL (Town) y.. (Street) (Lot Num6sr) DATE , par a/et OWNER OF WELL gi'fNDIVIDUAL 1lILDER ❑ OMER(Specify) s OWNER'S ADDRESS Q e Co ✓ -n, PROPOSED BUSINESS TEST Est.No.of ❑DOmEmc ❑ ESTABLISHMENT ❑ FA ❑ WELL People being USE OF served. WELL ❑ PUBLIC AIR OTHER SUPPLY ❑ INDUSTRIAL. ❑ CONDITIONING ❑ (Specify) j SKETCH OF WELL LOCATION Locale 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 Cf present) Indicate North CIL k � o rr✓. � w I'e• Approximate number of feet from well to nearest source of possible contamination: i The undersigned is aware that upon completion of the well,a"Well Completion Report" containing construetion 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 liy the Board. This permit Is not valid until all Information Is filled in and it has been countersigned by the Director of Health or his agent APPLICANT(Signature) APPLICANTS ADDRESS q �) /!1v (/[///��/// ,/�G O 6 REGISTRATION NO. r I • , /G d V I!�1 d Y�rA• N t�J�- ' � Town S oftker or Agent) DATE P4 • 1 ` REMARKS 711_j V* :. RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD ELL COMPLETJON REPORT D8:5. 12.69 REV.9-7 ' .• - �STATE,Op"CONNCC!t'• _ . WELL DRILLING 13 State Office HARTFORD,OCNNE uiiding O NAME ? iICU)06115� i StA D NOT fill I`tl WNER WE . . 9 LOCATION• - •" `f'f /► l/ �DRESS .- - OTHER NO. " ..- WEIR. �et.`. (No. OF ; ae At P S�OSED' DOMESTIC BUSINESS ~ ...................... .SO, (Town)• F. fid� Q- Cp yui�. ' OF PUBL( ❑ E HT � •"�','„`!CISCt^�•• (tor Number • ... WELL LISkAAE s SUPPLY ❑ INbU ❑ FARM • , DRILLING SFRIAE" AIR ❑TEST NFL(.` EQu1PMENT• ❑ ROTARY COMPRESSED a CONDITIONING OTHER CASING = .-LENGTH(fear) - FAIR"PERCUSSION Elf BLE.. (Specify) ` .. " DETAILS; �. DIAMETER(Fnchea) WEIGHT PF v PERCUSSIOj� y 6 R FOOT . ,❑ OTHER'•,. .., YIELD. z' 'I _ � �Speclfy) • TEST L�BAILED: PTHREADED. .,_:❑ DRIVE SHOE ' ❑ PUMPED• WELDED'•.❑yES LINO WCASING GROUTEDp WATER'' 'MEASURE FROM LAND - CI COMP 90URS fff L�JN ' LEVEL: " SURFACE=ST REED AIR 4 S. r ATIC.(SPeCify.feet •. ❑NO C d J DURI G YIELD LD Z N TEST I Z YIE (G.PM) MAKE (feet) SCREEN Depth of DETAILS SLOT SIZE Fn,feet t l n'Plethd We11, , ��, -• DIAMETER(inches) Land surface: /5r ; 'DEPTH:FR - IF GRAVEL _ - LENGTH OPE Oi{A[ANU P N i0 A rvel FEET fo FFETRFAC` ACKEDq'. i9iameter'o}wcl!'Includin GRAVEL: QUIFER(feet).. a FORMgTIpN'bESCRIPTION` 1 Eck'!inches):- g SI (Fn�es).FROM'(fee}) Sket ekact l exact ;,5, . :i �. F• h/. o Pcrmaneitt landmyI,all'with dFarences,to et le 9w s"�'wso'tw. asr t - If'yieli!was tested at lliffe '` FEE rant d T w epths duringd?illin_g,list below i . . .. ALLONS PER'MINUTE 7. %TE-WELL COMPLETEDPER PERMii NO.. RFGISTRATION:NO. ; REPORT WELL•DAIL LER(Sig ' n re): . �/ a WELL COMPLETION REPORT STATE OF CONNECTICUT WDB-5 12-69 REV. 9-71 WELL DRILLING BOARD DO NOT fill In State Office Building STATE WELL NO. HARTFORD, CONNECTICUT 06115 W t 0 OTHER NO, NAME p '7' /t �p ADDRESS OWNER I t ( /D if!f Lq R LOCATION (No.& Street) (Town) f / / (Lot Number) OF WELL t �)- � r S©V`�-f k W 1 'M✓C1 SBUSINESS O� ❑ ESTABLISHMENT ❑ FARM PROPOSED DOMESTIC ❑ TEST WELL USE OF WELL AIR OTHER ❑ PUBLIC SUPPLY ❑ INDUSTRIAL ❑ ❑ CONDITIONING (Specify) DRILLING COMPRESSED ABLE ❑ OTHER EOUIPMENT ❑ ROTARY ❑ AIR PERCUSSION "L—I' PERCUSSION (Specify) LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT CASING ��y DRIVE SHOE WAS CASING GROUTED? DETAILS Z�� I I f 7 I + I HREADED ❑ WELDED I ❑YES ❑NO �S ❑NO YIELD HOURS YIELD TEST L BAILED ❑ PUMPED ❑ COMPRESSED AIR MEASURE FROM LAND SURFACE-STATIC (Specify feet)I DURING YIELD TEST(feet) 2� WATER r I Depth of Completed Well LEVEL f '70 in feet below Land surface: MAKE I LENGTH OPEN TO AQUIFER(feet) SCREEN DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL I Diameter of well including I GRAVEL SIZE(inches) (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 j two permanent landmarks. , I � V { If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE 1 DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL D.1LLER(Signa/ure) DEPT. OF ENVIRONMENTAL PROTECTION -- WATER RESOURCES