HomeMy WebLinkAboutWell New 135 Troy Road State of Connecticut WILL COMPLETION REPORT DO NOT FILL IN
WATER RESOURCES COMMISSION This report must be completed and submitted j
223 State Office Building State Weli No.
to State Water Resources Commission no later
Hartford, Connecticut •than,30 days after completion of well. Other No. _
d� i—v6?
WELL
fL� +
OWNER
Name Street Addr2e CI d Town
WELL
DRILLER
Name Street Address / City anjVo
PROPOSED USE OR USES (Check):
Business
(,Domestic ❑ Farm ❑ Irrigation ❑ Establishment ❑ Municipal ❑ Industrial ❑ Test Well
CASING DETAILS YIELD TEST WATER LEVEL SCREEN DETAILS
1' Bailed (measure from land su ace)
or
Length: Feet ❑ Pumped Hours Static: - Feet Make:
/_ When Bailed Slot
Diameter: U� inches Yield: G.P.M, or Pumped/ Feet Length Ft. Size
DRILLING EQUIPMENT
Kind; p e Cable Tool ❑ Other (Specify) Diameter' In.
❑ Rotary
TOTAL DEPTH OF WELL1E'_�-5 —FEET
WELL LOG
Depth From Give description of formations penetrated, such as: peat, silt, sand, gravel, clay, hardpan, shale, sandstone,
Ground Surface granite, etc..Include size of gravel (diameter) and sand (fine, medium, coarse), color of material, structure
(loose,packed,cemented,soft,hard). For example:0 ft.to 27 ft.fine, packed,yellow sand;27 ft.to 134 ft. gray
granite.
FT.to 13 FT.
.tozom
to
FT.to/� FT. /
FT.to T ✓V .,s
FT.to FT.
FT.to FT.
FT.to FT.
FT. to FT.
YIELD TEST DATA IN G.P.M.
Give Depths At Which Yield Was Tested And Yield
FT. G.P.M.
G.P.M.
.4_
FT G.P.M.
FT. G.P.M.
Date-Well Was Completed: �� '_-o6 ✓ Date of Report
5�1 Cww,
1 < Y d Date y .
WELL DRILLER'S PERMIT
r., ..
�..
...,e�:.. ., of the firm of. ALP'
r
a
....................................... ... (address)
bereby;state that I (we) am (are) a well driller duly and currently registered with the State of Connecticut Water Resources
Commission and do make application herewith for a Well D•iller's Permit in accordance with the provisions of Public Act 187
of the 1963 Session of the Connecticut Legislature, for a well to be drilled on the property of:
Name,vf Property Owner ...x » ft:
at r
.....................................................
Address of Property Owner:... ..: '
.... .......
Address of Premises on which well is located:
k
X
The,approximate location of the well will be as shown on the reverse side of this permit.
The undersigned is aware that upon completion of this well the above data,together with a well log of informat on required
under,. and (d),of Public Act 187 of the 1963 Session must be sent to: Water Resources Commission, 223 State Office
Building, Hartford, Connecticut on the form entitled "Well Completion.Report"which has bepn supplied to registered drillers.
6 :.
r
p"plieant
This permit is issued for a well located as shown to the above named well driller xn accordance with the Provisions of
PubliC,Act 187 of the 1963 Session of the Connecticut Legislature this.. � " '""
day of....... $
:: , 196».. ....
WHITE—ISSUING AGENT e.:r r
GREEN—APPLICANT "" 3
„.................................
PINK—LOCAL HEALTH OFFICER 1�yu ldincg Off icial or Taw%,&Jerk
CANARY—WATER RESOURCES COMMISSION (Over)
ecticut
-S �RCES COM WELL COMPLETION REPORT
WATER RESOURCES COMMISSION
223 Stare Office Building This report must be completed and submltt DO NOT FILL IN
Hartford, Connecticut to State Water Resources Commission no la od
ter
than 30 days after completion of well. State Well No.-
WELL Other No.
_ OWNER
WELL Name
DRILLER Street Address
Name
and To
Street ddre _ A t
PROPOSED USE OR USES (Check): Litt nd Town
Q-tiomestic ❑ farm Business
U Irrigation 0Establishment
CASING DETAILS ❑ Municipal ❑ Industrial YIELD TEST ❑ Test Well
ailed WATER LEVEL
SCREEN DETAILS
Length: Feet or land su ace
umped (measure from la
❑ P ; !� � )
ours Static:
Diameter: Inches Feet Make:
Yield: G.P.M. When Bailed
or Pumped
Kind• Feet
Length Slot
�r � DRILLIN EQUIPMENT Ft. Size
@3<able Tool
TOTAL DEPTH OF WELL ❑ Rotary ❑ Other (Specify) Diameter:
—FEET I n.
Depth From WELL LOG
Ground Surface Give description of formations penetrated, such as:
granite, etc. Include size of gravel (diameter) and sand (fine
loose, Peat, silt, sand, gravel, clay, hardpan, shale
( packed,cemented,soft, hard). For example:0 ft,to 27 ft.fine sar
granite. , medium, coarse), color of material st useture
packed,yellow sand;27 ft.to 134 ft. gray
E FT.to� FT.
i
FT t
L---- //
FT.t ° �� r�4 fj J v
FT.to FT.
FT. to FT. Al, sid
YIELD TEST DATA.IN G.P.M.
1-7 1,7 j Give Depths At Which Yield Was Tested And Yield
/ 'AFT G.P.M.
i
9
FT. G.P.M.
FT. G.P.M.
FT, G.P.M. '__.---.—--
site Well Was Com pletbd:
Date of Report
i
Well Driller
C
(Signature)
Certificate No.
LOCATION OF WELL: TOWN OF
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
(Show distance and direction from road intersection or other landmark.)
DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
l�
wa'l
ROUTE DIRECTIONS FOR REACHING WELL SITE FROM NEAREST CITY OR VILLAGE CENTER:
STATE WATER RESOURCESCOMMISSION
�
RECEIVED
A+ SW;eR�D ----------------------
R zTERR ED___________________________________�
FILED..---.......
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