HomeMy WebLinkAboutWell New 00 Miller Road (3) btate of Connecticut WILL COMPLETION REPORT DO NOT FILL IN
WATER RESOURCES COMMISSION This report must be completed and submitted
223 State Office 'Building to State Water Resources Commission no later State Weil No.
Hartford, Connecticut than 30 days after completion of well:
( Other No. _
WELL
OWNER
Name
G
WELL street Ad ss City and Town
DRILLER y1
Name Street Address
City n own
PROPOSED USE OR USES (Check):
[g-Domestic ❑ Farm Business
❑ Irrigation ❑ Establishment ❑ Municipal p ❑ Industrial ❑ Test Well
CASING DETAILS . YIELD TEST WATER LEVEL
SCREEN DETAILS
ai ed (measure from land su ace)
Length: " Feet uinped / ► t fours Static:
-'f Feet Make:
Diameter: Inches Yield: G.P.M. When Balled Slot
or Pumped Feet Length Ft. Size
DRILLING EQUIPMENT
.Kind: ��� �Cable Tool ❑ Other (Specify) Diameter:----�
I n
❑ Rotary
TOTAL DEPTH OF WELL___
LL 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. is 134 ft. gray
granite.
FT.to FT.
G� FT.to?OFT. s^°
FT.to FT.
FT.to FT.
FT.to FT.
FT. to FT.
FT.to FT.
FT. to FT.
YIELD TEST DATA IN G.P.M.
Give Depths At Which Yield Was Tested And Yield
® FT. G.P.M.
FT G.P.M.
FT. G.P.M.
F.7 G.P.M.
Date Well Was Completed: Date of Rep ort
--Zz,��--�-
Well Driller
(Signature)
Certificate No.
LOCATION OF WELL: TOWN OF
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
(Show distance and direction from road intersection or other landmark.)
0
DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
/I
v �
ROUTE DIRECTIONS FOR REACHING WELL SITE FROM NEAREST CITY OR VILLAGE CENTER:
STATE WATER RESOURCES
COMMISSION
RECEIVED
ANEW R-J.--__--_-_
RcFFRRED_._._.
FILED--