HomeMy WebLinkAboutWell New 00 Niederwerfer Road WELL DRILLING BOARD STATE OF CONNEMCUT PERMIT NUMBER
WD54 11-69 WELL DRILLING PERMIT : . 59639
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 0611S
LOCATION OF WELL ( own) (8tseat)
(Lot Number) DATE
J1923J
OWNS WELL
INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED DOMESTIC BUSINESS❑ TEST Est.No.of ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF
OTHERPUBLIC AIR served.
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING. ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with resped 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 Of present)
Indicate North '
Approximate number of feet from well to D
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.
APPLICANT(Signature) I APPLICANT'S REGISTRATION NO.
BY(Town Seauk of#" dgeat
` I DATE
v� ❑ REJ
REMARKS n
CR w`C
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RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CON14EMCVT Do NOT fill in
WD&S 1249 REV.9-71 WELL DRILLING BOARD STATE WELL No.
c State'Office Building
HARTFORD,CONNECTICUT 0611S
OTHER-NO.
OWNER
NAWE ADDRESS-e4h&e — �
t
LOCATION (No.&St own) (Lot Number)
OF WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM
PROPOSED ❑ TEST WELL
USE L PUBLIC AIR OTHER
WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING MPRESSED CABLE OTHER
EOUIPMENT ROTARY AIR PERCUSSION PERCUSSION ❑ (Specify)
CASING
LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
I , 1 1 THREADED
DETAILS 1 ❑ WELDED ❑YES ❑NO ❑YES ,❑NO
YIELD ❑ ❑ COMPRESSED AIR HOURS YIELD
TEST BAILED PUMPED I
MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) !/ Depth WATER I ted in feet below Land surface:LEVEL /
MAKE _ (LENGTH OPEN TO A UIFER
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well including EL S GRAVIZE(inches)FROM(feet) TO(feet)
PACKED: gravel pack(inches): f
DEPTH FROM LAND SURFACI
FORMATION DESCRIPTION Sketch exact location of well with distances,to at least
FEET to FEET two permanent landmarks.
&2z"ke
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE%V COMPLETED I PE MIT NO, I REGISTRATION NO. DATE OF REPORT I WELL DRILLER nalvra)
BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT _
WDB-5 12-69 REV.9-71 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD, CONNECTICUT 06115
OTHER NO.
I NAME ADDRESS
OWNER rsT
LOCATION (No.&Stre own)
OF WELL OF Number)
DOMESTIC ❑ ESTABLISHMENT USINESS
PROPOSED ❑ FARM ® TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING ® (S(Specify)
DRILLING ROTARY MPRESSED ❑ CABLE El (Specify)
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
LENGTH (feet) DIAMETER (inches) WEIGHT PER FOOT
CASING DRIVE SHOE WAS CASING GROUTED?
DETAILS I _ I 3 I THREADED ❑ WELDED I (❑YES ❑NO I ❑YES NO
YIELD l HOURS YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED P-COMPRESSED AIR Z.WATER
MEASURE FROM LAND SURFACE—STATIC (Specify feet)I D eet)URING YIELD TEST (f Depth of Completed Well
LEVEL in feet below Land surface:
MAKE LENGTH OPEN TO UIFER(feet)
SCREEN
DETAILS SLOT SIZE I DIAMETER(inches) I IF GRAVEL Diameter of well including+ GRAVEL SIZE(inches)(FROM(feet) ITO(feet)
PACKED: gravel pack (inches):
DEPTH.FROM LAND SURFAC - -FEET FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
to FEET-
two permanent landmarks,
{
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If yield was tested at different depths during drilling, list below s
FEET GALLONS PER MINUTE
DATE WELL COMPLETED I PERMIT NO. I REGISTRATION NO. I DATE OF REPORT 4LLILLER }gnature)
EPT. OF ENVIRON JIENTAL PROTECTION-MiTE RESOURCES
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