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STATE OF CONNECTICUT WELL COMPLETION REPORT
WATER COMMISSION DO NOT FILL IN,317 STATE OFFICE BUILDING :� ,
HARTFORD 15 This report must be completed and submitted to STATE WELL N0. _-„
CONN. State Water Commission no later than 30 days
after completion of well. /^� OTHER N0.
WELL a V
OWNER
WELL
DRILLER [, Name' £/
�o�✓ Street Add ess
2t g' 1 r City or Town
.f Name . a�E G.is� � �.-...
Street Address _
City or Town
PROPOSED USE OR USES (check):
Domestic ❑Irrigation
❑Stock ❑Municipal (]Industrial {]Test Well
CASING DETAILS PUMPING TEST
WATER LEVEL SCREEN DETAILS
LENGTH: ._- FEET DURATION: (measure from Iona surface)
HOURS STATIC: r FEET MAKE:
DIAMETER: INCHES PUMPING RATE: SLOT
_ G.P.M. WHEN PUMPING: FEET LENGTH: FT SIZE
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KIND:
DIAMETER: IN.
WELL LOG
DEPTH FROM y Give details of formations penetrated, such as: peat, slit,sand,gravel,clay, hardpan,shale, stone,rock. Include size of ra
GROUND SURFACE (diameter)and sand (fine,medium,coarse),color of material,structure (loose, packed,cemented, soft, hard) g ve1—
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TE WELL WAS COMPLETED:__
DATE OF REPOR Z_e C;;
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WELL DRILLERk-- ``
_
✓ (Signature)
CERTIFICATE NO. ----_L -----------------------
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LOCATION OF WELL: TOWN OF _ � 4r
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
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DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
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ROUTE DIRECTIONS FOR REACHING WELL SITE FROM HARTFORD: `j r dt ej
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LOCATION OF WELL: TOWN OF _,' T`-,�
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
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DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
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ROUTE DIRECTIONS FOR REACHING WELL SITE FROM HARTFORD:�,
STATE 6F CONNECTICUT WELL COMPLETION REPORT DO NOT FILL IN
WATER COMMISSION
317 STATE OFFICE BUILDING This report must be completed and submitted to STATE WELL NO.z-`. ..�.. 3
HARTFORD 15, CONN. State Water Commission no later than 30 days OTHER N0. ..� .. .�.....
after completion of well.
WELL f
1
OWNER
Add reet 'ss
WELL ' Name St ,C-i or Town
DRILLER �, r ,,� at/'""' �''�"'*Y.�-�'�i- �� '?�.�e��• �'" '"'�
11
Name Street Address �� --
t - City ur Town
PROPOSED USE OR USES (check):
Domestic Irrigation L]Stock (]Municipal E] Industrial El Test We II
CASING DETAILS PUMPING TEST WATER LEVEL SCREEN DETAILS
(measure from land surface)
LENGTH: FEET DURATION: HOURS STATIC: s_ FEET MAKE:
DIAMETER: , INCHES PUMPING RATE: G.P.M. WHEN PUMPING SLOT
FEET LENGTH: FT. SIZE
KIND: —
DIAMETER: IN.
WELL LOG
DEPTH FROM Give details of formations penetrated, such as: peat, silt,sand,gravel,clay, hardpan,shale,stone,rock.—Include size of gravel
GROUND SURFACE (diameter)and sand (fine, medium,coarse),color of material,structure (loose, packed,cemented,soft, hard)
FT.to, FT.
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FT.to FT.
FT.to FT.
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eg5.:..� ,ten•''
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)ATE WELL WAS COMPLETED: ° DATE OF REPORT' € 3
WELL DRILLER
Signature)
CERTIFICATE NO. --__--