HomeMy WebLinkAboutWell New 00 Miller Road (4) WELL 1DRILLIMG BOARD•
STATE OF CONNECTICUT PERMIT NUMBER
wDe,a 111-64 WELL DRILLING PERMIT
2153
STATE.OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION F ELL(Town) .' Street) (Lot Number) DATE
OWNER OF WELL
❑INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER' ADDRESS
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PROPOSED ❑ ❑ BUSINESS TEST Est.No.of
DOMESTIC
USE.OF : I• ESTABUSHMENT ❑ -FARM ❑ WELL People being
WELL ❑ PUBUC AIR OTHER served.
SUPPLY - ❑ INDUSTRIAL ❑ 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 at least two roads Well location on lot and to house(if present) '
Indiea North `F
L ,
47 A_ __7__
R1l
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pproximate number of feet from well to
nearest source of possible contamination: ��' ' '1w✓�� C
The undersigned is aware.that upon completion of the well;a"Well(completion Report:eontainingLconsiruction details and information required.under Section.6 of
Public Act 659 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 alt•informa-
Non is filled in and it has been counter-signed by thw Director of Health or-his agent.
(Signatu APPL S ADDRESS REGISTRATION NO.
64
A, i
BY ffasi Hearth ffi or Agent '
DAT��
❑APPROVED ❑ REJECTED - �' ! � 8 •
REMARKS I 7
DIRECTOR OF HEALTH
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
virDla a l 1-69 WELL DRILLINGPERMIT 2 IT! 3
w }' STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
'LOCATION F WELL(Town) Street
-- ry � •'!• � .��' ) (lot Number) DATE .
OWNER OF WELL j'
❑INDIVIDUAL BUILDER ' :OTHER(Specify)
OWNER' ADDRESS
PROPOSED ❑ f BUSINESS TEST Est.No.of
USE
DOMESTIC ESTABLISHMENT ❑ FARM El-WELL People being
OF
WELL PUBLIC `;, ❑ AIR ❑ OTHER served.
❑ SUPPLY .v0 INDUSTRIAL 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 at least two roads Well location on lot and to house(if present)
- Indico NorthVA
jod
jr
a [J1
pproximate number of feet from 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 6 cf .
Public Act 659 must be sent to the owner,the Board and the Water Resoijrces Commission on the form provided by the Board.This permit is not valid until all informo-
tion is filled in and it has been countersigned by the Director of Health or his agent,
PLI (Signature V APPLIC T'S ADDRESS ^' ,,. REGISTRATION NO.
BY(io, Fkalth Off Agent•4 iv p DAT
❑APPROVED ❑ REJECTED
��� C�
REMARKS „
DIRECTOR OF HEALTH
WELL COMPLETION REPORT STATE OF CONNECTICUT -
WDB-5 12-69 WELL DRILLING BOARD STATE WELL NO.
State Office Building
HARTFORD,CONNECTICUT 06115 -10 3
OTHER NO.
NAME 12 ADDRESS
OWNER !`
_ y a/'(.+�' �.��, - - � (--"`�" .lr'1 �,_P -```r�.✓'�✓ter_..,
LOCATION No. & treet) (Town (Lot Number)
r OF WELL ��y� �� #
BUSINESS
PROPOSED V DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
USE OF
WELL PUBLIC AIR ER
❑ SUPPLY ❑ INDUSTRIAL ElCONDITIONING (Speif )
DRILLING a COMPRESSED CABLE El
EQUIPMENT u ROTARY IJ AIR PERCUSSION ❑ PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS , V THREADED El WELDED ❑YES ❑NO ❑YES ❑NO
r i
YIELD
TEST ❑ BAILED ❑ PUMPED ® HOURS G.P.M. YIELD(G.P.M.)
COMPRESSED AIR
r
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) tjD.pth of Completed Well
LEVEL 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
FORMATION DESCRIPTION FEET. to FEET two permanent landmarks.
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If yield was tested at different depths during drilling, list below Y
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. =DATEF REPORT WELL DRILLER nature)
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