HomeMy WebLinkAboutWell Repair 353 Troy Road WELL EXCEPT ION REQtTEs T
TO:
DATE:
ON--SITE SEWAGE DISPOSAL SECTION
DEPT. or PUBLIC HEALTH & ADDICTYCN SERVICES
150 WASHINGTON STREET
HARTFORD, CT o61os
FROM: TELEPHONE; � ,�-�
OWNER 2w z- REPAIR NEAP SYSTEM
ADDRESS:- _ �U PERC FASTER THAN 1 XZN/INCW,;;,i; 0
Town: NO. OF BEDROONS
OR, DESIGN FLOW
EXCEPTION FOR INSTALLATION OF TANX____TANK & SYST=__.SYSTEM
WELLS AFFECTED: OWNERS ONLY— BTGHHOR9 ONLY�,QOTIi��
AFFECTED PROPERTY LOT NO: TYPE DISTANCE OF W!To*
(IF APPLICABLE) OR ADDREss WELL N
EW TANX NEW
PROPERTYPon
3�� Irv=� I�hfllY
ADS'WE" PROF.
ADJACENT PROP.
RIGHT ST E
ADJACENT PROF.
DEFT S
ADJACENT PROP.
IS REPLACEMENT SYSTEM CLOSER TO WELL(je) THAN EXISTSNG SYSTEMS?
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HAS THE WELL l BEEN ANALYZLM RECMMY Fall POLLUTANTS? .... hJ
PLAN MWAM -BY.- PROF.ENO:�.._.INST1it�LER:, pTfLER:
j;BUILDING BEEN CONVERTED TO YEAR ROUp USE OR LNLARGEp SINCE I977?
COMMENTS: ✓.� �G �-
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ENCLOStM;
SKETCH/P I ( � � GNATURE
WELL COMPLETION REPORT STATE OF CONNECTICUT Do
CPR-9 REV.9-79 DEPARTMENT OF CONSUMER PROTECTION NOr fill in
WELL DRILLING BOARD STATE WELL
u No.
20 GRAND STREET
HARTFORD,CONNECTICUT 06106 OTHEF NO.
NAME __ __ ADDRESS _- --
OWNER EDWARD MYERS 353 TROY RD. , S. WINDSOR, CT.
LOCATION (No..&Street) (Town) __ (Lot Number)
OF WELL 353 TROY ROAD S. WINDSOR
PROPOSED ® DOMESTIC ESTABLISHMENT BUSINESS D EARN a TEST WELL
USE OF
WELL ❑ SUTHER
PPLY INDUSTRIAL 0 CONDITIONINGBLIC (Specify)�((Specify)
DRILLING f—VI THER
EQUIPMENT ® COMPRESSED ROTARY AIPERCUSSION PERCLUSSION (specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT AS CASING GROUTED?
DETAILS 198 G 1 .4 ®THREADED El WELDED YES NO 61 YES ❑NO
YIELD ❑ 1:1a COMPRESSED AIR HOURS 6 YIELD(G.P M) 50
TEST BAILED PUMPED
--j
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 10 100 in feet below Land surface: 205
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feel
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.
0 84 Sand & Gravel
84 188 Clay
188 205 Red Rock
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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 DR (Signature)
8 1 82 Ol 100 2 2
BOARD
CONSUMER PROTECTION
WELL DRILLING BOARD STATE OF,CONN9l`ICUT PERMIT NUMBER
CPR-8 REV.e.79 DEPARTMENT OF CONSUMER PROTECTION 70177
WELL DRILLING PERMIT
20 GRAND STREET,HARTFORD,CONNECTICUT 06106
LOCATION OF WELL(rowrr) (Street) (Lot Number) DATE
SOUTH WINDSOR 353 TROY RD. .. 8/10/82
OWNER OF WELL p�
® INDIVIDUAL BUILDER OTHER(Specify) EDWARD krMS (2894009)
OWNER'S ADDRESS
353 TROY RD. , S. WINDSOR, CT.
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ESTABLISHMENT ❑ FAWN WELL People being
USE OF served.
PUBLIC AIR OTHER
WELL 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 roods Well location on lot and to house(if present)
G
Indicate North
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Approximate number of feet from well to 80�+
nearest source of possible contamination:
•The undersigned is aware- that upon completion of the well, o "Well Completion Report" containing construction-details and information required under Section
2-4 131 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
Board.This permit is not valid until all information is filled in and it has been countersigned by the Director of Health or his agent.-
APPLICANT'S ADDRESS REGISTRATION NO.
P.O. Box 111II Willingtont Ct. 100
BY(Town Health O&er nt) DATE
APPROVED REJECTED
REMARKS
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RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD