HomeMy WebLinkAboutWell New 00 Berle Road WEH-DRILUhG BOARD STATE OF CONNECTICUT PERMIT NUMBER
wDB a I1-69 WELL DRILLING PERMIT 10848
STATE OFFICE BUILDING;HARTFORD,CONNECTICUT 06115
�(J
LOCATION OF WELL{T (St (Lot Number) DATE
OWN WELL
INDIVIDUAL ❑BUILDER ❑OTHER(Specify)
OWNER'S ADDRESS
PROPOSED ❑ BUSINESS TEST Est.No.of
(-f DOMESTIC
USE OF ' ESTABLISHMENT FARM❑ ❑ WELL People being
_ served.
WELL BLIC El El INDUSTRIAL ❑ CIONDITIONING ❑ (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 lot and to house(if present)
D
Indicate North
Q
Approximate number of feet from well to
nearest source of possible contamination:n- lam/ �_
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 Gofer*Stetr>7ei must be sent to-the owner,the Board and the Water Resources Commission.on the'form provided by the Board.This
permi ' of valid until all informi i'op is filled' and it has been counter-sig b Director alth or his agent.
94
APP w CANTS REGISTI(ATION NO.
APpROYED e -n. BY..1Town tkoUh Officer or Agent DATE
El REJECTED
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
: WELL COMPLETION•REPORT: STATE OF CONNECTICUT Do NOT fill in
WDB-5 1269. REV.9-71 : WELL DRILLING•BOi4RD" SATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
r OTHER NO.-
NAME :I ADDRUS
W ONER '
-LOCATION (No.&•Street) (Town) (Lot Number)
OF WELL
BUSINESS
PROPOSED'.' w "OMESTIC. •. •.. L�ESTABL•ISHMENT •- ❑ Q.7EST WELL'
FARM '' .
USE OF,
WELL PUBLIC AIR.. ( ' OTHER
0 SUPPLY.' :INDUSTRIAL - CONDITIONING ' L,J (Specify).
GRILLING ` MPRESSED .' CABLE —( OTHER'
EQUIPMENTROTARY AIR PERCUSSION PERCUSSION' LJ (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT ��-y/ DRIVE.SHOE -WAS CASING GROUTED?
.DETAILS I I 'ILI THREADED' ❑ WELDED I YES ONO 'YES , .a NO
YIELD (� HOURS YIELD(G.P.M.)
TEST Cl BAILED .: F1 PUMPED [ErCOMPRESSED AIR I
MEASURE FROM LAND SURFACE—STATIC(Specify.feet) -DURING YIELD TEST(feet)
WATER. Depth of Completed.Weil
LEVEL I' I in feet below Land surface: /
G MAKE- _ LENGTH OPEN TO AQUIFER(feet)
'SCREEN
DETAILS LOT SIZE [DIAMETER
(inches) ' IF GRA Diarnefer of well including GRAVEL SIZE(inches)FROM(feet) . TO(feet)
I PACKEDVEL: '( gravel pack(inches): I
DEPTH FROM LAND SURFACEFORMATION DESCRIPTION ;Sketch ekact location of well with distances,to at least
'FEET -to FEET ' two-permanent landmarks.
' -. - • is -
If field was,te'steii et d' tip• aSFd"u�ii f "fii6w
Y: _ f M:.�;(�..
FEET.-' x ?: GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE:OF REPORT WELL DRILLER ignature)
67
BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-S 12.69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115
5 irt1 �49
x f OTHER NO.
NAME �� r� ADDRESS
OWNER
1
LOCATION (No. & Street) (Town)
OF WELL (Lot Number)
( BUSINESS
PROPOSED s DOMESTIC ❑ ESTABLISHMENT ❑ FARM USE OF El WELL
PUBLIC AIR
THER
WELL ❑ SUPPLY ❑ IN ❑ CONDITIONING ' ❑ ((Specify)
DRILLING .ROTARY COMPRESSED El
❑ OTHER
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH (feet) DIAMETER(inches) WEIGHT PER FOOT
I DRIVE SHOE WAS CASING GROUTED?
DETAILS I I 7 THREADED ❑ WELDED ❑YES ❑NO ❑YES ❑NO
YIELD HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED F—WCOMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet)I DURING YIELD TEST(feet)
Depth of Completed Well
LEVEL in feet below Land surface:
MAKE 1
SCREEN LENGTH OPEN TO AQUIFER,(feet)
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL
Diameter of well including I GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED: gravel pack(inches): 1 1
DEPTH FROM LAND SURFACE
---------------------
FEET to FEET
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
two permanent landmarks.
ITO
if yield was tested at different depths during drilling, list below. —
FEET GALLONS PER MINUTE
DATE ^WELL OMPLETED PERMIT NO.� REGISTjz,uION NO. I DA"rTg3E OAF�REPORTr WELL DRI'LLEP45ignature)71
DEPT. OF ENVI ONPAENTAL PROTECTION