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STATE OF CONNECTICUT STATE WELL NO.
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
OWNER NAME ADDRESS
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LOCATION (No.s Street) (Town) (Lot Number)
OF WELL 313 :::tronq l—? `i-Du t h 4indior
DOMESTIC D BUSINESS a FARM TEST
PROPOSED ESTABLISHMENT WELL
USE OF WELL a SPUBLIC UPPLY � INDUSTRIAL OTHER
� CONDITIONING � (Specify)
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE �WAS CASING GROUTED?
DETAILS 149 5 17 THREADED WELDED YES ❑ NO, U YES ❑ NO
YIELD TEST a BAILED a PUMPED a COMPRESSED AIR HOURS YIELD(GPM)
4 10
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well in feet
LEVEL 260 2?
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED: including gravel pads
(inches)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
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If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
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DAJE,jL4TJrPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Sig re) f-
LOCAL DIRECTOR OF HEALTH