HomeMy WebLinkAboutWell New 490 Niederwerfer Road r"GRR-8 Rev.1/95 PERMIT NUMBER
- ' • STATE OF CONNECTICUT 176411
` DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
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165 Ca itol Aven e,Hartford,Conn_ectic t 0610
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LOCATION OF WELL (Town) (Street) (Lot Number) DATE
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OWNER OF WELL
to INDIVIDUAL BUILDER El OTHER(Specify)
OWNER'S ADDRESS
1
Est No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL PUBLIC
SUPPLY INDUSTRIAL AIR 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 roads Well location on to and to house(if present)
Indicate North
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Approximate number of feet from well to a +
nearest source of possible contamination: �O
The undersigned is aware that upon completion of the well,a"Nell 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 an the form provided by agency. This permit is not valid until all information is filled in and it has been counter-signed by
the Director of Hea his agent.
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APPLICANT(Signature) APPLICANTS ADDRESS REGISTRATION NO.
CONNEOCUT Y o' LOT kalvrmbya
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' BY(Town Health OficerorAgeny DATE
I.APPROVED, REJECTED n ^ Z y L' ;L(^97
REMARKS p QCy�
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RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
CPR-9 Rev.7/95
Do'NOT-filFin,°
f STATE OF CONNECTICUT STATE WELL NO.
DEPARTMENT OF CONSUMER PROTECTION
k REAL ESTATE&PROFESSIONAL TRADES DIVISION
OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
ADDRESS
LOCATIC." 'r-"�OK� 6sneetl (Town) (LO(Number)
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OF 1. v
DOMESTIC BUSINESS FARM TEST
PROPOSED ESTABLISHMENT WELL
USE OF WELL a PUBLIC INDUSTRIAL AM DITIONING OTHER
SUPPLY
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT �AIR PERCUSSION PERCUSSION (Specify)
CASING LEN TH(feet) DIAMETER(indw) 7V*MPERFOOT ORNE SHOE WAS CASING GROUTED?
DETAILS r^�[ ® THREADED WELDED
� DYES ❑ NO YES ❑ NO
YIELD TEST aBAILED ❑ PUMPED [K COMPRESSEDAIR HOURS YIELD(GPM)
lb
WATER MEASURE FROM LAND SURFACE-STATIC(Spedfy feet) DURING YIELD TEST(fee) Depth of Completed Well in feet
LEVEL .� 0 ! C-4—
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(bxhes) IF GRAVEL Diameterofwell GRAVEL SIZE(iidm) FROM(feet) TO(feet)
! PACKED: inducing V-rel pack
(fie)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exaCt location of well with distances,10 at(east two
FEET TO FEET permanent landmarks
y 114- 14 o clk
ow gat If s,
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DA OF ORT WELL IL
CONNECTICUT VALLEY ARTESIAN WELL CO. 14C
AGENCY