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HomeMy WebLinkAboutWell New 677 Rye Street PERMIT NUMBER CPR-8 Rev.7/95 191677 t STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION REAL ESTATE&PROFESSIONAL TRADES DIVISION WELL DRILLING PERMIT 165 Capitol Avenue,Hartford,Connecticut 06106 vov�-.v Wi�✓dso Rxe Sr 477 LOCATION OF WELL (Town) (Street) IJ.aI Number) DATE OWNER OF WELL L.•J jam{,-VDIVIDUAL- BUILDER OTHER(Specify) OWNER'SADDRESS- 44 7-7 - �YE csr ev H iNLSolL CT Est.No.of PROPOSED ET'DOMIESTIC BUSINESS FARM TEST People being USE OF ESTABLISHMENT WELL served. . WELL PUBLIC - SUPPLY INDUSTRIAL CONDITIONING STHER L 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 ono and to house if present) (D . I gAar� SSA Indicate North Q - Ado,r)�;✓: ' - G • G�fy1•)N 5: $EYLR LINE - r Approximate number of feet from well to 7 / nearest source of possible contamination: /, The undersigned is a e that upon completion of the well,a'Well Completion Report"containing construction details and information required under Section 25431 of t 1 9 Supplement to the General Statutes must be sent to the owner, the Department of Consumer Protection and the Water Resources Commiss n f r vided by the agency. This permit is not valid until all information is filled-in and it has been counter-signed by the Director of Health r is APPLICANT(S)gnature), APPLICANT'S ADDRESS REGISTPATION NO. Will --N W -- :.- Po IVA o!o BY(Town Health Officer or Agent) DATE 0_11POVED ❑ REJECTED -49 V O —? r p q AJ r L ! REMARKS RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION CPR=9 Rev.7 = Do NOT fill in STATEOrCONNECTICqW STATE WELL NO. r DEPARTMENT OF CONSUMER PROT!ftlt REAL ESTATE&PROFESSIONAL TRADES DIV � f 1 OTHER NO. WELL DRILLING COMPLETI(} REPO �r f 165 Capitol Avenue,Hartford,Connec ut D8106 9,40V[�?, OWNER­ NAME ADDRESS .- LOCATION //-7 (nro.s Street) (Town) `- (Lot Num ) OF WELL (f/ /-7 1-21 ca I � (N.C/lIGLoO� . -v V DOMESTIC BUSINESS FARM TEST ' -PROPOSED 1C ESTABLISHMENT - WELL USE OF WELL ❑, PUBLIC ❑ INDUSTRIAL a AIR a OTHER SUPPLY CONDITIONING (S DRILLING a ROTARY ® COMPRESSED a CABLE - OTHER EQUIPMENT AIR PERCUSSION PERCUSSION (Specify) CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED? DETAILS /a / //J © THREADED ❑WELDED (f / YES ❑ NO, W/YES ❑ NO YIELD TEST a BAILED ❑ PUMPED © COMPRESSED AIR HOURS YIELD(GPM) WATER MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well in feet LEVEL v?U" a� MAKE LENGTH OPEN TO AQUIFER(feet) SCREEN DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL-SIZE(ir") FROM(feet) TO Qoet) PACKED: including gravel pads . _ (inches) DEPTH FROM LAND TO SURFACE .FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two FEET M FEET permanent landmarks a '�G0/w i/e- eck If yield was tested at different depths during drilling,list below FEET GALLONS PER MINUTE }�0 DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WE RILLER(Signature) WIN 300111 . VALLEY ARTESIAN WELL CO. INS AGENCY