HomeMy WebLinkAboutWell Repair 55 Windshire Drive 9_YN,UNMK rKv wu i ivN
WELL DRILLING BOARD STATE OF-COWECTICUT PERMIT NUMBER
CPR-8 REV.11-82 DEPARTMENT OF CONSUMER PROTECTION 89302
WELL DRILLING PERMIT _
165 CAPITOL AVE.;HARTFORD,CONNECTICUT Ot5106
LOCATION OF WELL (Iowa) (Suet:) (Lot Nwraber) BATE
S. wIr6DSOR 55 WIVI)SHIRE DR. 9/7/8<+
I OWNER OF WELL
® INDIVIDUAL „ ❑ BUILDER ❑ OTHER(Specify)„ ROBERT KAMY11SKI 635-3331 - 547-3969
OWNER'S ADDRESS
! 55 WIXIDSHIRE DR:, S.. WDIDSOR,• CT.
I
PROPOSED BUSINESS TEST Est.No.of
® � ESTABLISHMENT ElFARM ElWELL People being
USE OF served.
WELL ❑ SUPP Y ❑ INDUSTRIAL ❑ ONDITIONING (SPeErfY) 4
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 lot and to house(if present)
• tJL
0
Indicate North
G ,- -
- E h
11
Wt�` pr. •
X
C.yj'144rlll.%? c D.P_
Approximate number of feet from well to 5!
nearest source of possible contamination:
The undersigned is aware that upon completion of the well, a "Weil 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.
(Si atwre APPLICANT'S ADDRESS REGISTRATION NO,
P.O. BOX 111, S. WILIDSOR, CT. 100
APPROVED
BY(Town Health Officer or Ageat) DATE
❑REJECTED
REMARKS 7
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT' -
CPR-9 REV.n-as DEPARTMENT OF CONSUMER PROTECTION Do NOT fill i'n
WELL DRILLING BOARD STATE WELL NO.
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME ADDRESS O�q�{�gg
OWNER BOND o S e WINDSOR . s
No.& Street (Town) (Lot Number)
LOCATION q�� �g^� ( ) Town y�
OF WELL 55 WViDSR� DR. S. WLIDSOR
DOMESTIC El ESTABLISHMENT HMENT FARM
BUSINESS
PROPOSED
TEST WELL
USE OF
PUBLIC AIR
WELL SUPPLY INDUSTRIAL ❑ CONDITIONING ((Spec fy)
DRILLING EQUIPMENT � COMPRESSED OTHER
ROTARY AR PERCUSSION PERCUSSION (Specify),
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT D IV SH WAS CASING GROUTED? _
DETAILS 50 19+ 5 SO THREADED WELDED ®YES NO ®YES NO
YIELD ❑ BAILED a PUMPED COMPRESSED AIR HOURS YIELD(G.P.M.)
TEST
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) of Completed Well
LEVEL 20 1 ti TD-pthn feet below Land surface: 230
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feet
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET TO FEET two permanent landmarks.
0 6 Sa v Gravel t
r�
6 G0 Gla7
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 WEL. tER(Signature