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STATE OF CO NNECTICUT STP.TE WELL NO.
R DEPARTMENT OF CONSUMER PROTECTION
REAP.(ESTATE Bt PROFESSIONAL TRADES DIVISION
OTHER NO.
WELL DRILLING COMPLETION REPORT
16S Capitol Avenue,I+a^rrtlord,Connecticut 08106
OWNER NAME
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LOCATION (.vc Sr:eK_;i L- f`Ta w I iL :r a per f
OF WELL � • �If�
OOMES.IC t75iNESS FARM �' TEST
PROPOSED ESTABLISHMENT i WELL
USE OF WELL r �:
❑ PUBLIC INDUSTRIAL El
A'sR OTHER
SUPPLY —CON OIT(ON1NC �I (Specify)
DRILLING ROTARY r �.'- ::*MPRESSED CABLE 171 OTHER
ct2:11Pfs!EN i + AIRPERCUSStOV PERCUSSIMq 1 �? (•Sperl(y)
CASING LEIN;::7i e! D..;.`.! . j R. .-..'.bc: f .it:� `:_P= . _-. i}�} � ...—, ..�.�.� :. ♦.. ... _- ...
DETAILS5
ETAIL& (i `(e ( �+� 1 ��� rr �•ti W
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YIELD TEST 9Ak:ED �( ''�( PUMPED COMPRESSEDA'R I OJ:M
-
WATER MEASURE FROM LAND SURFACE-STATIC(Specfry•anti DURING YIELD TEST ft?ek'
LEVEL '
MAKE LENGTR OPEN TO AOUIFE^ net)
SCREEN
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DETAILS SLOT SIZE DIAMETER(inches) i IF GRAVE! D ameter otvrel GRAVEL SIZE(inches) FROM(IeeN TO(feet)
PACKED: +rkutling gravel pack
(inches! '.
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DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION 1 Sketch exact location of well with Cistances.to at)anal two
FEET TOFEET permanentiandmarks i
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If yield was tested at different depths dkk^ng drilNng,list below I
FEET GALLONS PER MINUTE 4
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DATEVVELL CO PIL PERW.T NO Ru'G;STRAT:ON O C#LT�,r�O R O.T LL DROLLER t nal
'x 7 1) �. v ^ j ` J ..
_f LOLL
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AGENCY
£'d 069ZZ£ti0981, s3noodr dt,V7, 60 01, OeG
CPR-8 Rev.7/95 PERMIT NUMBER
STATE OF CONNECTICUT 245792
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106 j�f
LOC ON OF LL Uj,,(Towj (Sheet) ( t Num r) ( b DATE //0
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OWNER OF WELL V I
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INDIVIDUAL BUILDER OTHER(Specify) UkV
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SADD
1/ Vr! RESS
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WEL served.
WELL served
WELL m
PUBLIC SUPPLY INDUSTRIAL AIR Ot
CONDITIONING (STHERpecify) �� `
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 to and to house(if present)
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Indicate North
Z 30 2-
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Approximate number of feet from well to �^ t
nearest source of possible contamination:w
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 Department of Consumer Protection and the Water
Resources Commission on the form provided by the aj7X4Wen00snot valid until all information is filled in and it has been counter-signed by
the Director of Health or his agent.
APPLIC (Signature) APPLICAN 'S ApDRESS,_ REGISTRATION NO.
(L�„ ([\JGJt b — V t-s-a
Y(T H alth r or A en DATE
APPROVED ❑ REJECTED
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-MARKS
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DIRECTOR OF HEALTH