HomeMy WebLinkAboutWell New 260 Smith Street WELL DRILLING BOARD STATrWOF CONNECTICUT PERMIT NUMBER
t"DB4 11-6' WELL DRILLING PERMIT 8799
y ' STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL wnj ry (Lot Number) DATE
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OWNER OF WELL
INDIVIDUAL ❑BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
USE OF DOMESTIC ❑ ESTABLISHMENT ❑ FARM- ❑ WEIL People being
WELL ❑ PUBLIC ❑ ❑ AIR OTHER served.
SUPPLY INDUSTRIAL CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to of feast 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)
Indicate North rc
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Approximate number of feet from well to r
nearest source of possible contamination:
The undersigned is aware that upon completion of the well,a"W omple Rep rt'containing construction details and information required under Section 6 of
Public Act 659 must be sent to the owner,the Board and the WaF Resources om sion on the form provided by the Boa�his permit is not valid until all informo-
tion is fille has b7ounfer-siepj by the Director of or is a ent.
arore) APPLICA 'S ADD 55 REGISTRATION NO.
BY(o Heah%,Officer A J DATE /
N APPROVED El REJECTED �" l
REMARKS Of
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNFCTICUT Do NOT fill in
WDB-5 14'-69 WELL DRILLING BOARD srarE WELL No.
State Office Building
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HARTFORD,CONNECTICUT 06115
OTHER NO.
N ADDRESS
OWNER
LOCATION (No..4 41ree n) Mtr
e
OF WELLBUSINESS
1
PROPOSED DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ 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) DIAMETER(inches) WEIGHT PER F99T (� D i E SHOE WAS CA SING OU ED?
DETAILS rz IQI THREADED ❑WELDED YES ❑NO ❑YES NO
YIELD HOURS G.P.M. YIELD(G.P.M.j
TEST ❑BAILED ❑ PUMPED Ef CO
WATER MEASURE FROM LA)SURF.ACE—STATIC et) DURING YIELD TEST(feet) Depth of Eomplumd'Wool
LEVEL In feet below Land surface:
MAKE LENGTH EN O UIFER(/eet)
SCREEN
DETAILS LOT
IZE DIAMETER(inches):JIFGRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(test) TO(feet)
CKED: grave(pack (inches):
DEPTH FROM LAND SURFACE •Sketch exact location of well with distances,to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
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kiln
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If yield was tekeP,&Xifferenj&ths dv ng drilling,list below
T GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT REGISTRATION NO, DAY OF REPOT WELL D g e)
BOARD