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WRL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD44 11-6.9 WELL DRILLING PERMIT 4 2�'
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (Toiaw) (Street) (Lot Number) ) -DATE
SOUTH WINDSOR ROSEMARY T ANB I, I TTcrn zn -t nrza
OWNER OF WELL
❑ INDIVIDUAL [ BUILDER ❑ "TREK(specify).
OWNER'S ADDRESS
71 LINDEN STREET, GLASTONBURY. CT,ESS TESTEat.No.of
PROPOSED [2 DOMESTIC ❑ .EBSTARUSHMENF ❑ FARM ❑ 1NELL People being
USE OF served.
WELL PUBILIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDMONING 1_i (Specify) cL
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 Of present)
Indicate North
Ilk-
.A1(3't3 y 2or� Ecc..
- E?cTt�i(,�S/O�rJ fly3�Y 2vq.t� .��Y�/f1Slati
Approximate number of feet from well to
nearest source of possible contamination SANITARY SEWER
The unde IfcLrj d is aware that u on comp tion of the well,a'Well Completion Report" containing construction details and information required under Section
2S- of the 19 Supplement t the Gen ral Statutes must be sent to the owner,the Board and the Water Resources Commission on the form provided by the
rd. This perm' is valid un• all information is filled in and it has been countersigned by the Director of Health or his agent.
APPLICANT ' APPLICANT'S ADDRESS REGISTRATION NO.
Cy `I LAKE STREET VERNON CONN. 100
� 8Y � each Officer or dy ) � I DATE
APPROVED ❑/REJECTED r C3,..r 7 y
REMARKS
pas
RETURN THIS COPY. TO CONNECTICUT WELL DRILLING BOARD
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
OTHER NO.
NAME I ADDRESS
OWNER (v_ _q
s-1-t rs ,,,it.J,'w�,.a_ t 3.:'.t s.rC1 st..1.}s --.. a ;TC; '7 L 3 i 1 3 .'-'t S 3T G Lt..�,.;7I H, '., ..Lx$ ,301 7�i
„lsr,.-1.�.. 3.,,'i a S.: -I'a5 j.V.s ,'. I �. _v° s
LOCATION (No.&Street) Crown)
(Lot Number)
OF WELLBUSINESS
a DOMESTIC ❑ ESTABLISHMENT ❑ FARM
PROPOSED ❑ TEST WELL
USE OF
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL
❑
❑ CONDITIONING (Specify)
DRILLING ❑ COMPRESSED CABLE ❑ OTHER
❑
EQUIPMENT ROTARY AIR PERCUSSION ❑ PERCUSSION (Specify)
CASING LENGTH (feet) I DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS a f ' ILaLj THREADED ❑ WELDED I Ila,[YES ❑NO RYES
YIELD HOURS �g YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR I 4 14
MEASURE FROM LAND SURFACE--STATIC(Specify feet) DURING YIELD TEST(feet)
WATER Depth of Completed Well
LEVEL 0 in feet below Land surface: 3
r
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER (inches) IF GRAVEL Diameter of well including I GRAVEL SIZE(inches)IFROM(feet) 1TO(feet)
`PACKED: ( gravel pack (inches):
DEPTH FROM LAND SURFAC FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
"i < _t
01.1 s"
� 1
If yield was tested at different depths during drilling, Fist below
FEET GALLONS PER MINUTE
1
DATE WELL COMPLETED PERMIT NO REGISTRATION NO. DATE OF REPORT WEiI�D;MtER('Signature)