HomeMy WebLinkAboutWell New 00 Long Hill Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD" 11-69 WELL DRILLING PERMIT 38415
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 ^
a
So u 7 H W! r4 io s'p lit' c: d/'(6- iy 1�t G A p, f 6-11-
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
�j7 17 -7
OWNER OF WELL
INDIVIDUAL � BUILDER � OTHER(specify)
OW ER'S ADDRESS
/ X �Grl� 17" t�L IQ A Sd�i .'V to So15'_
PROPOSED BUSINESS 1:1TEST Est.No.of
OOMESnC ESTABLISHMENT FARM WELL People being
USE OF served.
WELL PUBLIC AIR OTHER
SUPPLY 1:1INDUSTRIAL CONDITIONING (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 t'least two roads Well location on lot and to house(if present)
Indicate North
pelf
30 /
-- -7° 1 ,.
Approximate number of feet fiom well to
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 _
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. This permit Is not valid until all Information Is filled In and it has been counter-signed by the Director of Health or his agent.
jg:�,;1 7 0e
APPLI N (Sig ure) I APPLICANT'S ADDRESS
! REGISTRAT
ION NO.
BY sr or.Lyent). DATE
E3 APPROVED ❑ REJECTED �. I �t ,,,77
REMARKS
' RETURN TH.IS_,COPY TO CONNECTICUT WELL DRILLING BOARD
r, . .
_..' S __
WELL COMPLETION REPORT STATE OF CONNECTICUT
• Do N07 fill in
WDB-5 12.0 REV.9.71 WELL DRILLING BOARD
STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115
OTHER NO.
OWNER
NAME ( ADDRESS
LOCATION -..7 0.&Sire (To ) (Lot Number)
OF WELL
P BLISH
ROPOSED DOMESTIC ❑ ES MENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) _
DRILLING ❑ ROTARY A RM ERCUSSION ❑ PERCUSSION El (PRESSED CABLE (
THER
EQUIPMENT (Specify)
-
i
LENGTH(feet) DIAMETER(inches)I WEIGHT PER FOOT DRIVE SHOE I WAS CASING GROUTED?CASING I
DETAILS I �j '"r �� l I THREADED•_❑ WELDED( YES ❑NO YES ❑NOYIELD i
HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Spe&y feet) DURING YIELD TEST(feet) j Depth of Completed Well .
LEVEL ( I 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 SURFACf
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
If
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION O. DATE OF REPORT LET; re
BOARD