HomeMy WebLinkAboutWell New 00 Chapel Road State of Connecticut WELL COMP! 1O REP® DO NOT FILL IN
WATER RESOURCES COMMISSION This report must be completed and submitted State Well No__�.
317 State Office Building to State Water Resources Commission no later
Hartford 15, Conn. than 30days after completion of well. Other No.
WELL
OWNER '�!yl
WELL Name Street Addre
City and Town l
DRILLER
Name -"Street�Add sa Pity and Town
PROPOSED USE OR USES (Check):
❑ Domestic El Farm Business
❑ Irrigation ❑ Establishment ❑ :Municipal ❑ Industrial ❑ Test Well
CASING DETAILS YIELD TEST WATER LEVEL SCREEN DETAILS
❑ Bailed (measure from land surface)
or
Length: 7 7 feet ❑ Pumped Hours Static: Feet Make:
When Bailed Diameter: Inches Yield: G.P.M. or Pumped ?4 Slot
Feet Length Ft. Size
Kind: Diameter: In.
TOTAL DEPTH OF WELL _FEET
WELL LOG
Depth From Give description of formations penetrated, such as: peat,silt, sand, gravel, clay, hardpan,shale,sandstone,
Ground Surface granite, etc. Include size of gravel (diameter) and sand (fine, medium, coarse), color of material, structure
(loose,packed,cemented,soft,hard). For example:0 ft.to 27 ft.fine,packed,yellow sand;27 ft.to 134 ft. gray
granite.
FT.to7 FT.
FT.t f FT.
FT.to FT.
FT.to FT.
FT.to FT.
FT.to FT.
,FT .to FT.
FT. to FT.
FT. to FT.
FT.to FT.
FT.to FT.
FT. to FT.
FT. to FT.
Date Well Was Completed l Date of Report ✓ ®�
s
Well Driller "
(Signature)
Certificate No. a�xt's
LOCATION OF WELL: TOWN OF
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
(Show distance and direction from road intersection or other landmark.)
l
DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
i
ROUTE DIRECTIONS FOR REACHING WELL SITE FROM NEAREST CITY OR VILLAGE CENTER:
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