HomeMy WebLinkAboutWell New 00 Burnham Street "L`WEIL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
wDB4 11-69 WELL DRILLING PERMIT 1593
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 0611.5
ell a o v/Z 20 `' c5'
LOCATION F WELL(i nJ (Street) (Lot Number) DATE
OW ER OF WELL
'INDIVIDUAL ❑BUILDER ❑OTHER(Specify)
OWNER'S AD RESS
PROPOSED BUSINESS TEST Est.No.of
USE OF KI-50MESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
WELL ❑ ❑SUPPLY ❑ INDUSTRIAL served.AIR El (Specify)
CONDITIONING (Specify) 7
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersectio and front of lof
Location of lot to at least two roads Well loco on on lot and to house(if present)
Lo4
Indicate North A
wa-
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Cr
OL
Approximate number of feet from well to r7�
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 6 of
Public Act 659 must be sent to the owner,the Board and the Water Resources Commission an the form provided'by the Board.This permit is not valid until all-informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
APPII not ) ^ AP -ANPS DV*
REGISTRATION NO.
BY(Town Hoc rcer or Agenjr DATE
,PROVED ❑ REJECTED
REMARKS
,� RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
t
WELL COMPLETION REPORT STATE of CONNECTICUT ---
WDB-5 12-69 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115 V'j
OTHER NO.
NAME a ADDRESS
OWNER
(No. & Street)
LOCATION (Town)
(I nt NnmhAr)
OF WELL '�
BUSINESS
PROPOSED DOMESTIC ❑ ESTABLISHMENT ❑ FARM USE OF ❑ TEST WELL
PUBLIC R
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING OTHER)
DRILLING ❑ ❑ COMPRESSED t CABLE ❑ OTHER
EQUIPMENT ROTARY AIR PERCUSSION LX PERCUSSION (Specify)
CASING MENTH(feet) DIAMETER{inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS ❑ THREADED ❑WELDED YES ONO DYES NO
YIELD HOURS G.P.M. YIELD(G.P.M.)
TESTBAILED ❑ PUMPED ❑ COMPRESSED AIR t r
WATER MEASURE FROM LAND SURFACE—STATIC(Specityfeet) DURING YIELD TEST(feet)
Depth of Completed Well
LEVEL in feet below Land surface: �
MAKE -
LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well incu g GRAVEL SIZE(inches) FROM(feet)- TO(feet)
ldin
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET to FEET two permanent landmarks.
ji
If yield was tested at different depths Mlinbeol
FEET
DATE WELL COMPLETED PERMIT NO. TE OF REPORT WELL DRL.LL•E'R77'Signature)
41
E:F A- —f,
'11�ELL COMPLETION REPORT STATE OF CONNECTICUT
WDB-S 12-69 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115
OTHER NO.
NAM
OWNER
ADDRESS
�
LOCATION (No.d Street) J( (Town) (lot Number]
OF WELL
BUSINESS
PROPOSEDI DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR ElSUPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER
fy)
DRILLING COMPRESSED EQUIPMENT El ROTARY ElA R PERCUSSION � PERCUSSION El ((S CABLE pecify)
CASING LENGTH(feet) DIAMETER(Inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING G OUTED? —
DETAILS ' Q'. ❑ THREADED ❑WELDED YES ❑NO ❑YES NO
YIELD HOURS G.P.M. YIELD(e.p.M.)
TEST BAILED ❑ PUMPED ❑ COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Spec/fy feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL 00 in feet below Land surface: ��
MAKE LENGTH OPEN TO AQUIFER(feet]
SCREEN
DETAILS SLOT-SIZE DIAMETER(Inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances,to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
eL
-. .4�
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED I PERMIT NO. REGISTRATION NO. DATE OF R=T WELL D Ignet j
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BOARD