HomeMy WebLinkAboutWell Repair 85 Petersen Way MLCDRILUNG BOARD ..STATE OF CONNECTICU7 PERMIT NUMBER
11-69 WELL DRILLING PERMIT
55860
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 0611S
LOCATION OF WELL ) (Street) (Lot Number) DATE
OWNER OF WELL -
❑ INDIVIDUAL N BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
P ARM
ROPOSED f( � nC BUSINESS ❑ ❑ TEST / Eat.No.of
Yr� ESTABUSHMM f WELL. People being
USE OF
OTHERPUBLIC served.
WELL ElSUPP Y ❑ INDUSTRIAL ❑ CIONDRIONING ❑ (Specify) 3 6
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing.distance from intersection and from of lot
Location of bt to at least two roads Well location on tot and to house Cif present)
indicate North `s
_ P .00
a
3 p "v ,r_....
_ Rom
Approximate number of feet from well to
nearest source of possible contamination: V
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 Board and the Water Resources Commission on the form provided by 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.
APPL T S( uro) I APPLICANT'S ADDRESS a RWISTSL�TION NO.
Y(Town HW&h Officer or Ap ) , DATE
"APPROVED ElREJECTED
REMARKS
RETURN THIS COPY TO-CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT --- --
WDB-5 1269 REV.9-71 WELL DRILLING BOARD Do NOT fill in __
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115
OTHER NO.
OWNER NAME ADDRESS
Framk 0avalier 718 1ington Rd,,_So.o. Ln(i1sor, Colm. 06074
LOCATION (No.&Street) (Town) (I nt Number)
OF WELL 1833 �`ra�.11in-eyon Rd. So. 14inL sor §2
❑ BUSINESS
ESTABLISHMENT ❑ ❑PROPOSED DOMESTIC FARM TEST WELL
USE OF
WELL PUBLIC AIR
ElSUPP Y ❑ INDUSTRIAL OTHER
❑ CONDITIONING ❑ (Specify)
DRILLING El ROTARY COMPRESSED CABLE ❑ OTHER
EQUIPMENT AIR PERCUSSION ❑ PERCUSSION (Specify)
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT CASING DRIVE.SHOE WAS CASING GROUTED?
❑YES
DETAILS 8 I 6 I17 lbs. I � THREADED ❑ WELDED I : ❑NO ❑YES ❑NO
YIELD HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED 1-4�1 COMPRESSED AIR I
MEASURE FROM LAND SURFACE—STATIC (Specify feet)I DURING YIELD TEST (feet) 4 hours
WATER Depth of Completed Well
LEVEL �. ? t. in feet below Land surface:
3e
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inch Diameter of
es) I .
IF GRAVEL 1 well including (GRAVEL SIZE(inches),FROM (feet) ITO(feet)
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFAG Sketch exact location of well with distances, to at least
FEET to FEET FORMATION DESCRIPTION
two permanent landmarks.
0 70 sand
70 165 red sandstone
.0
I
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
4
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. (DATE OF kLPORT WELL DRILLER(Signature)
. iV.=.i`l ti-t� f'i a1dTEy�I l'eretN WATER ?'{f`J`v U5C.i.=9