HomeMy WebLinkAboutWell New 646 Strong Road ,CON16MER PROTECTION �'j�C1/ �/'j(/J►
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
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cPR-a 11ey.,t1-a2 DEPARTMENT OF C NSOMER PROTECTION 02876
WELL DRILLING PERMIT �$ ,9
165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106
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LOCATION OF W (Town) (Sneer) (Lot Namber) DATE
OWNER EL
INDIVIDUAL ILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
[!�J "" ❑ ESTABLISHMENT ❑ FAQ ❑ .WELL People being
USE OF served.
WELL PUBILIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING a OTHER
if)
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)
Indicate North
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
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
Boor This permit is not valid until all information is filled in and it has been countersigned by the Director of Health or his agent.
1 T(Sr are) APPLICfANNT'S ADDRESS REGISTRAT NO.
U •
BY(Town Health Officer or Agent) DATE
APPROVED ❑R D �r
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
CPR-9 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in
WELL DRILLING BOARD STATE WELL NO.
165 CAPITOL AVE.
HARTFORD, CONNECTICUT 06106 OTHER NO.
ENAME — - JADDRESS
OWNER
6 V t e L4—c1 K G'16 � 00je woodLOCATION (No. 8 Street) (Town)OF WELLOIV6 _ )9.b ZOU7' L/ O (Let Number) --
PROPOSED 11!2j� DOMESTIC ESTAIBLI HMENT
USE OF FARM a TEST WELL
PUBLIC
WELL SUPPLY AIR❑ INDUSTRIAL CONDITIONING a OTHER
DRILLING COMPRESSED
EQUIPMENT ® ROTARY ® AIR PERCUSSION (- l ABLE OTHER
u PERCUSSION (Specify)
LENGTH feet DIAMTER PER FOOT IV H
YES
/� E (inches) WEIGHT NO wqs EASING GROuiED?DETAILS ® THREADED
CASING S ®
WELDED YE
YIELD U NO
I HOURS YIELD (G.P.M.)
TEST BAILED PUMPED 1_21 COMPRESSED AIR /
WATER
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet)
LEVEL Depth of Completed Well
in feet below land surf.
�� !�� ce:
MAKE
SCREEN
LENGTH OPEN TO AQUIFER (feet)
DETAILS SLOT SIZE DIAMETER(inches)
IF GRAVEL Diameter of well including GRAVEL SIZE (inches) FROM(feet) TO(feet
PACKED: gravel pock(inches):
DEPTH FROM LAND SURFACE
FEET TO FEET FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
two permanent landmarks.
e25' r�'o G�+9NiP�
30
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
+T 8 fQ a,?'& 00 WELL DRILLER(Signature)
DEPT. OF ENVIORNMENTAL PROTECTION-WATER RESOURCES