HomeMy WebLinkAboutWell Repair 00 Windsorville Road WELL COMPLETION REPORT STATE of CONNECTICUT
WDB-5 12-69 REV.gar WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115
OTHER NO.
NAME ADDRESS T �gp� rr y��`m
OWNER OIAM THERI" I 15 BOUT` ST. s WINDSOR �3*�*CK&I, C0117.
LOCATION
�y (No. &Street) (Town) (Lot Number)
y�
OF WELL WIND 011VI I+ ROAD {�.i.Fl WI MORBUSINESS
® ❑ ESTABLISHMENT HMENT ❑ FARM
PROPOSED DOMESTIC ❑ TEST WELL
USE OF
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING ® ROTARY ❑ AIR PERCUSSION COMPRESSED ❑ CABLE ❑ (Specify)(
EQUIPMENT PERCUSSION
LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
CASING
DETAILS I 119945
I � THREADED ❑ WELDED I YES ❑NO ❑YES NO
YIELD I HOURS y YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED ' COMPRESSED AIR "P
14
WATER
MEASURE FROM LAND SURFACE—STATIC(Specify feet)I DURING YIELD TEST(feet) I Depth of Completed Well
�
LEVEL in feet below Land surface: 96
MAKE I LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL Di
I meter of well including I GRAVEL SIZE(inches) FROM(feet) TO(feet)
Diameter
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACEI
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET
two permanent landmarks.
12 T=soil
end & Gravel
Gravel
r6r
If yield was tested at different depths during drilling, list below \ ) y
_ r
FEET GALLONS PER MINUTE �i 3
f, A 1i1k
W um
DATE WELL COMPLETED I PERMIT NO I REGISTRATION NO. DATE OF REPORT WELL DRILSignat e) ';
DIRECTOR OF HEALTH
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
wDB-4, 11-69 WELL DRILLING PERMIT 14686
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL(Town) (Street) ' (Lot Number) DATE
SOUIS WIAllSOR WIRDSORVII► A ROIL 2/1/73
OWNER OF WELL
1i INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) OLIM . HERI"
OWNER'S ADDRESS ill
15 SOUTH S2. WM B DR LOMSt COMA,
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ OTHERPUBLIC AIR
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
Location o$lotto at least two roads Well location on lot-and to house(if present) .
Indicate North 4,
Ujljt suftd,Ltc
"R°A°
/yv L)S e
ST
I C r
Rr F�iv Ro.9D � � i✓`
;.,y u
Approximate number of feet from well to
nearest source of possible contamination: 85
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 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 counter-signed by the Director of Health or his agent.
-i%7APP (Sign at re) APPLICANT'S ADDRESS REGISTRATION NO.
Gv T.ArR ROP6 Can• 100
8 n He h Offi or Agent) DATE
APPROVED ❑ REJECTED y
REMARKS
C 11 t 64L me. -14
DIRECTOR OF HEALTH