HomeMy WebLinkAboutWell New 1127 Sullivan Avenue r � •
CONSUMER PROTECTION .�f
WELL DRILLING BOARD r STATE OF CONNECTICUT PERMIT NUMBER
CPR-8 REV.11_e2 DEPARTMENT OF CONSUMER PROTECTION 103218
WELL DRILLING PERMIT
165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106
LOCATION OF WELL (Town) (Sheet) (Lot Number) DATE
S.. WIIIDSOR �� SUMIVA-'f AVE. 5/28/85
OWNER OF WELL
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) P.S. ASSOCIATES
OWNER'S ADDRESS
P.O. BOX 735 tTAREHOUSE POIAT, CT. 06088
PROPOSED DOMESTIC
❑ BUSIN TEST Est.No.of
® ESTARLISHINENT ❑ FARM
ESS ❑. .WELL People being
USE OF
served.
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ •(Specify)
4
SKETCH OF WELL LOCATION,
Locate well with respect to of least two roads,showing distance from intersection and.front of lot
Location of lot to at least two roads W ocotion on of and to ho (if present)
Q's
Indicate North ih
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Approximate number of feet from well to -
nearest source of possible contamination: 7 5 T
i
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 ond'the Water Resources Commission on the form provided by the
Board.This permit is not valid until oil information is filled in and it has been countersigned by the Director of Health or his agent.
APPII NT lure APPLICANT'S ADDRESS
REGISTRATION-NO.
P.O. BOY ].11 T S. �,II ,LIiu G"'Oiy, CT. -
BY(Town Health Officer or Agent)APPROVED El REJECTED
PATE^ cr'"— I—CIS-
REMARKS �
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Awe 70
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
CPR-9 REV.11_92 DEPARTMENT OF CONSUMER PROTECTION Do NOT fill in
WELL'DRILLING BOARD STATE WELL NO.
165 CAPITOL AVE.
HARTFORD, CONNECTICUT 06106 OTHER NO.
NAME ADDRESS
ASSOCIATES OWNER P*So TES P s O s BOA
LOCATION SULLIVAN
& Street) (Town) r, (Lot Number)
t,3
OF WELL 312? LLIV . AVE• 3• WIXiDSO
BUSINESS
PROPOSED DOMESTIC ESTABLISHMENT El FARM
y'USE OF � TEST WELL
WELL ❑ OTHERPOBLIC AIR
SUPPLY INDUSTRIAL CONDITIONING (Specify)
DRILLING
THER
EQUIPMENT L& COMPRESSED ROTARY A R ER USSION PERCUSSION ' O(Specify)
CASING LENGTH(feet) DIAMETER (inches) WEIGHT PER FOOT RIVE SHOE was CASil'i GROUTED?
DETAILS R THREADED WELDED YES NO YES NO
YIELD HOURS YIELD (G.P.M.)
TEST BAILED PUMPED 12 COMPRESSED AIR 6n
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) V
Depth of Completed Well
LEVEL 2O 175
in feet below Land surface:
MAKE 200
LENGTH OPEN TO AQUIFER (feet)
SCREEN
DETAILS SLOT SIZE DIAMETER (inches) GRAVEL SIZE (inches) FROM(feet) TO(feet
IF GRAVEL Diameter of well it .uding
PACKED: gravel pock(inches):''
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET TO FEET =;=two permanent landmarks.
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If yield was tested at different depths during drilling, list below J f
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRAT PORT
ION NO. DATE OF RE WELL LER(Signature)
1 6 2 8 --
DEFT. OF ENVIRONMENTAL PROTECTION-WATER R1=,czr 11Prll=c