HomeMy WebLinkAboutWell Abandond 11 Mountain View Road ujl:lvlull lb:58 8604295158 STAVENS BROTHERS RAGE 01/02
0F., �(.O.N.NECTICU T
---- �0-EPARTMENT OF-CONS ERPROTECTION
RLwL ESTA't E& Pl;Ol-CSSIONAL'i'ttADES
WELL ABANDONMENT. YL1IFI(.AIION OF TVORK COi-VIPLETED
6's a:caiva-es fldls=- : All procedures used to abtndula u well shall 1'01101► rebut.itioats established utttler•
Stedon 23-128-56 and 25-128-57 of the State of Connecticut well Drilling Board Reaulatim S(sec a[tiach-
iaeftc)- Thtse regulations require that at registered well drilling contractor perlortat the work.
For water supply wens attach completed form to Well Permit, For non-Water supply wells attach sketch
of wcil location to completed farm. Distribution: Department of Consumer Protection,Depgrtment of
F.tivironracatal Protection, Properly Owner, Well Drilling Contractor., I.orril l)irectnr of Health.
`I"ttwn* j'���{ 3C� Date work completed:
Marna'ist`t)avna:r:
I.MA t
Locauana of well(if different from above):.21 )A t k 1 c_ %ACC r
Type of well(drilled,point,duo,.etc.): s
Bepth of»etl:
DiararTer Uf well: W t 1 (���� •
Length of vasing: Wow
Wort:gglal s a f gMer inform atia
IVA3'Yie of ra•;istrt'ta31Yr11 da'illit:g cvaltracteir pei'forralital;'FYArIi: -, � 1 .� _, ���'��',� .
Rtaister ai well drilling manta aCtw3r's liceltse type & �Y___;I-#r 1-tr3-#
Materials-Used; Amotult of wild
• arnouat.tttcl type(s)of brOtit ce meni..
llracrif,tiUtt atF work conlpla:ietl: ICAj_cd ,
T
71
5ititla�d: iYt'-1! £�t'tllitttr
# CUtltr•'aCiur�
Ib�Cnpitol Avenue, HartfcirL.t, Cc7MI'e:tictat 04?100-7630 _
Fax: (t 60)566 63t, � 'ri.�:(860)564-]347
:°lis /jirmatit+r. c�r�rr/&PS-tIOppoftwi►:r�£,tt ipycr
16:58. 8604295158 STAVENS BROTHERS PAGE 02/02
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25-12's-
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.1 lifts 11-111.% Pvr Illillivil(.150 lipm) tif villoviliv. t}lla
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am f-.v;livr ur tilltreeti! d..
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tit.11n olmt fist tia:311 III--.1 I will ilircri-criv with
11,; %%dt hurc!ilmll lit filled mud-livaletj Ividy ;,fly uritit-10101ving 111jEeriah; he.11
�ftrvlll,or saild clay or bvii(ouile culvivist gj*tItIi. Oro
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lit a cuilsolitlawd IV& A.0-MA(juit, i1jily be fille(I %viril lifie Snuff I!, -r 7N consoh-
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ITOM W file I:
por
sh-311 1r filled %vill; atry of me imiteri;,li its
IC1t licit qr bure Nlj;llI be.16miduntal all ;t Ill-41111C.1, that it klvci trill becollir I v- for A
.44-v gf.%f 9-.1 4AM.11vi-til, ro file pul;,bla: gI-tillis-1
i't
of Iiii Ivells wifil ;.:.-1AII1N fl,el: of e(vildilng, tudow flit Wa gr; At Cr
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;iUmsdolisliclit of liar IVIA1. ilit; (op 4 tilt valial.) ur gruitt inalcrial w
(4!Jett befull- life vrolind suff-we,
W.
k i'Ict:41 hl-.1y 2,1.VVj_1
F'LL LOCATION
1wCatiull of well with dist'auce!i to tit lt!;tit r1fry_p�rtnitnenf -vh rki
t �i111e. d - - - .
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