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HomeMy WebLinkAboutWell New 47 Troy Road CONSUMER PROTECTION WELL DRILLING 'BOARD STATE OF CONNECTICUT PERMIT NUMBER CPR-$REV.11-92 DEPARTMENT OF CONSUMER PROTECTION WELL DRILLING PERMIT 171771 r 165 CA TOL AVE.,HARTFORD,CONNECTICUT 06106 LOCATION OF (Tour aft") 0 (Lot Number) OA OA?rER ll ' gO1V101JAt BUILDER OTHER(specify) OWNER'S ADDRESS PROPOSED BUSINESS TEST Est.No.of ESTABLISHMENT FARM WELL People being USE OF served. WELL PUBLIC AIR OTHER SUPPLY 0 INDUSTRIAL CONDITIONING (Specdy) SKETCH OF WELL LOCATION Locale well with respect to at least two roads.showing distance from intersection and from of lot Location of lot to at bast two roads Well location on lot and to house (if present) tndioote Noah 2 Approximate number of feet from well to nearest source of passible contamination; The undersigned is aware that upon completion of the well, o "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 Booed.This permit is not valid until all information is filled in and it has been covnier-signed by the Director of Health or his agent. AM (Sgwf a APPLICANT'S ADDRESS REGISTRATION NO. BY(Tonne Hedth Officer or ATe � DAT l� VEO REJECT CD Div I� S Poe V RETURN THIS COPY TO CONNECTICUT WELL DRILUNQ SOARD- CPR-9 Rev.7/95 X�T fi[� STATE OF CONNECTICUT STATE WELL NO. DEPARTMENT OF CONSUMER PROTECTION REAL ESTATE&PROFESSIONAL TRADES DIVISION OTHER NO. WELL DRILLING COMPLETION REPORT " 165 Capitol Avenue,Hartford,Connecticut 06106 OWNER NAME ADDRESS R1?BFRT SIDOR 24 4f1A1n.-QRr. 06074 LOCATION (No.&Street) (Town) (trot Number) OF WELL 47 TROY RD. , . S. Wl/!i Fr CT 47 BUSINESST PROPOSED DOMESTIC a ESTABLISHMENT FARM WELL USE OF WELL PUBLIC a INDUSTRIAL 1:1AIR OTHER SUPPLY CONDITIONING (Specify) DRILLING ROTARY COMPRESSED CABLE OTHER EQUIPMENT © � AIR PERCUSSION1:1 PERCUSSION 1 (Specify) CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED? DETAILS JE] THREADED WELDED ❑ YES ❑ NO ❑.'YES ❑ NO YIELD TEST - E]BAILED Q PUMPED ❑ COMPRESSED AIR HOURS YIELD(GPM) `5F }^t WATER MEASURE FROM LAND SURFACE-STATIC(Specify feel) DURING YIELD TEST(feet) Depth of Completed Weil in feet LEVEL MAKE SCREEN LENGTH OPEN TO AQUIFER(feet) DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(feet) TO(feet) PACKED: including gravel pack (inches) DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two FEET TO FEET permanent landmarks 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 WELL DRILLER(Signal re) DEPT.OF FNVIR0Nhf11FNTA1 PRnTFt'TInN..9hFdT=Q MmeNt imr%ca