HomeMy WebLinkAboutWell Abandond 1546 John Fitch Boulevard S �lryA .�, C0N' .: ECTIC U 'Y'
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-- DEPARTMENT OF CONSUMER PROTECTION
RCA1LESTATS & 1'RO CSSIONALTRADES
WELL ABANDONMENT, 'VE1tXIi 1CATION OF WORK COi`il'LETED
f'ruceLiures followed: All procedures used to abandon a well shall follow regulations established uncle-
Section 25-128-56-2krid 25-128-57 of the State of Connecticut Well Drilling Board Regulations (see attach-
,rteat). 'rtiese regulations require that a registered well drilling contractor perform the work.
r'or%vater supply-wells attach completed form to Well Permit. For non-water supply wells attach sketch
of well location to completed form. Distribution: Department of Consumer Protection, Department of
1:11vir011raental Protection,Property Owner, Well Drilling Contractor, &ocAl Director of Health.
1Vcil information:
Town: SOi J-10 r Date wort: completed:
Name of Owner:
Adcttess: �1!, 3
Location of well (if different from above):
s. n
'Type of well (drilled, point, dtrb,.etc.): Depth of well:
Diamerer of well: la Length of casing:
Work details and other information:
Name of registered well drilling contractor performing work: peven S
Registered well drilling contractor's license type & #: _vvV1=#� �`� �W3-#
1Vlateriitls Used: amount of sand
amount and type(s) ofgrout — Ce m e4vt al t'n�'
s
1)rseription of tivorl:completed:
(well drilling; contractor)
165 Capitol Avenue, Hartford, Connecticut 06106-1630
Fix: (860)566-7630 9 TDD: (860)566.1547
An A irmathie Action/.Eclrnr!Opyortunir / Employer
` CPR-8 Rev.7/95 PERMIT NUMBER
STATE OF CONNECTICUT 248649
DEPARTMENT OF CONSUMER PROTECTION
r REAL ESTATE&PROFESSIONAL TRADES DIVISION
_ WELL DRILLING PERMIT
16S Capitol Avenue,Hartford,Connecticut 06106
' LOCATION OF WELL (Town) (Street) (Lot Number) DATE
South Windsor 1546 Joh n Finch Rlvd 10I27/10
OWNER pF WELL
INDIVIDUAL BUILDER El OTHER(Specify)
OWNER'S ADDRESS
Full Line Auto 1546 John Finch Blvd South Windsor
Y f
PROPOSED DOMESTIC BUSINESS FARM TEST Est.No.of
People being
USE OF ESTABLISHMENT WELL �ty�
WELL
ElPUBLIC INDUSTRIAL AIR _ OTHER JNbandg d well
SUPPLY a CONDITIONING (Specify)
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)
Indicate North
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Approximate number of feet from well to
nearest source of possible contamination:
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
ResourcesoCommissio on the form provided by the agency. This permit is not valid until all information is filled in and it has been counter-signed by
the Dire r of H or his a ent.
APPLI NT APPLICANT'S ADDRESS REGISTRATION NO.
Joel Stavens PO Box 046 Willington 42
EJOBY(Town Health Officer or Agent) DATE
ROVED ❑`REJECTED
REMARKS
DIRECTOR OF HEALTH