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WELL DRILLING BOARDS a STATE OF CONNECTICUT PERMIT NUMBER
wDe-a Ii`-69 WELL DRILLING PERMIT 1789
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL(Town) (Street) (Lot Number) DATE
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OWNER OF WELL
.INDIVIDUAL ❑BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
3 dl-
PROPOSED ❑ BUSINESS TEST Est.No.of
USE OF O DOMESTIC ESTABLISHMENT ❑ FARM ❑ WELL People being
PUBLIC served.
WELL El SUPPLY ❑ 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 roads Well location on lot and to house(if present)
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Indicate North p y t�
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Approximate number of feet from well to
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 6 of
Public Act 659 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 informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
APPLICANT(Signature) ��TAPPUCANT'S ADDRESS /�++ REGISTRATION NO.
t Gi y W 'b o �- O y
BY(T can Health Officer or Agent) DATE
❑APPROVE ❑ REJECTS 4',-_ , /0- 76
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDS-5 12-69- WELL DRILLING BOARD Do NOT fiH in
STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
NAME ADDRESS
OWNER K -f- I l/j l
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LOCATION ( o.6 Street) (Town) (Lot Number)
OF WELL X/_CVC}! / GQ A JAJ AP0-
BUSINESS
PROPOSED
L J DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING El (specify)
DRILLING PRESSED
EQUIPMENT ❑ ROTARY AIR ERCUSSION ❑ P RBCUSSION ❑ OTpeHER cify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE PW CASING GR�jUTED?
DETAILS t r 6 ZI-THREADED ❑WELDED Z'YES ❑NO IvfYES LJ NO
YIELD HOURS G.P.M. YIELD(G.P.M.) � r
TEST ❑BAILED ❑ PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feeU DURING YIELD TEST(feet) Depth of Completed Well
LEVEL in feet below Land surface.
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE 7—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.
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21'
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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 IWELL DRILLER(Signet e)
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BOARD