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CONSUMER PROTECTION
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
CPA-8 REV.111-82 DEPARTMENT OF _CON-SWER PROTECTION 103259
WELL DRILLING PERMIT
165 CAPITOL AVE.;HARTFORD,CONNECTICUT 06106
LOCATION WELL(!'oran) (Sweet) (Lot Number) DATE
OWNER OF WELL SOP
�.INDIVIDUAL BUILDER OTHER(Specify)
•OWNER S ADDRESS c.. �o�
PROPOSED BUSINESS TEST Est.No.of
USE OF
DOMESTIC ESTABLISHMENT FARM ❑ WELL People being
WELL PUBLIC AIR HER served.
SUPPLY INDUSTRIAL CONDITIONING (SSppe )
SKETCH OF WELL LOCATION
Locate well with respect to of least two roods,showing distance from intersection and front of tot
Location of lot to of least two roads Well location on lot and to house(if present)
Indicate North
Approximota number of feet from well to ��0
nearest source of possible contamination:
The undersigned is aware that upon completion of the well, a "Well Completion Report- conloining construction details and information required under Section
25-131 of the 1969 Supplement to the General Statutes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the
Board.T . permit is not valid until all information is filled in and it has been counter-signed
by the Director of Health or his agent.
APPL
fSigx e) NT hC
- PIJ7-- 4t w REGISTRATION NO.
a7 7/
BY(71omn Health Officer or A My DATE
APPROVED REJECAD
REMARKS or
111 !�f 7
60
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL-'COMPLETION REPORT- STATE OF CON"ECTICUT Do NOT fill in
CPR-9 REV.11-e2 - DEPARTMENT,OF CONSIIldIER PROTECTION • STATE WELL NO.
WELL"DRILLING BOARD: '
165 CAPITOL AVE. OTHER.NO. ~
HARTFORD,CONNECTICUT 06106 ,
NAME �7 j. Y ADDRESS
OWNER' `
LOCATION (No.&Street)' �(T•own) (Lot Number)
OF WELL �� .. 7 _•.L!�
_ B(JSINESS •_
PROPOSED DOMESTIC ESTABLISHMENT a FARM a TEST WELL
USE OF '
WELL PUBLIC- AIR OTHER
El S PPL-Y INDUSTRIAL. El CONDITIONINGa(Specify) -
EQUIPMENT •.� ROTARY DRILLING �PERC SSION PERCUSSION ®((Specify)14 'r �
C TEO?.•
CASIf� LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT -
DETAILS ! a a �THREADED •-a WELDED YES � NO H W-*G
YES Imo(NO
YIELD• HOURS. YIELD(G,P.M.)
TEST BAILED Q PUMPED a COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE=STATIC(Specify feet). [DURING YIELD TEST(fiat) Depth of Completed Well
.LEVEL :`� in feet.below Land'surfote:. _
MAKE S�S LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS VOTIZE DIAMETER(inches) GRAVEL SIZE(inches) FROM(feet) TO(feet
/ IF GRAVEL Diameter of well including
PACKED: gravel pack(inches):. .
pEfrlff FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location,of well with distonces,to of 16ost
FEET TO FEET two permonent.londmarks.
�31V _
If yield was tested'at different depths during drilling',list below
FEET= GALLONS PER MINUTE
DATE WELL ETED r PERMIT NO. REGISTRATION NO. DATE OF REPORT E ILL (Si ur
BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
CPR-9 REV.n-es DEPARTMENT OF CONSUMER PROTECTION Do NOT fill.in _
_ STATE WELL NO.
WELL DRILLING BOARD
165 CAPITOL AVE."
HARTFORD, CONNECTICUT 06106 OTHER NO.
NAME J t ADDRESS t
OWNER
No. tree
LOCATION ' ( & S t) (Town) (Lot Number)
OF WELLBUSINESS
PROPOSED Ln DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF
PUBLIC AIR E]
WELL SUPP Y EJ INDUSTRIAL CONDITIONING (OTHER Specfy)
DRILLING COMPRESSED CABLE OTHER
EQUIPMENT ROTARY A R PERCUSSION PERCUSSION ® (Specify)
CASING LENGTH(feet) DIAMETER (inches) WEIGHT PER FOOT (RIVE SHOE WAS CASING GRO TED?
DETAILS t q ® THREADED WELDED LJ YES ®NO YES NO
YIELD HOURS YIELD(G.P.M.)
TEST BAILED ® PUMPED COMPRESSED AIR
WATER MEASURE FROM ND SURFACE—STATIC(Specify feet) DURING YIELD TEST f`t) Depth of Completed Well > t`
LEVEL in feet below Land surface:
MAKE LENGTH OPEEN TO AQUIFER (feet)
SCREEN
DETAILS SLOT SIZE , DIAMETER(inches) IF GRAVEL Diameter of well including GRAVEL SIZE(inches) FROM(feel) TO(feet
/a►a- 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.
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
7eVEL,LC PERMIT NO. REGISTRATION NO. DATE OF REPOT E RILL (Sgwatur
DEPT. OF ENVIRONMENTAL. PROTECTION-WATER RESOURCES