HomeMy WebLinkAboutWell New 00 Pleasant Valley Road STATE OF CONNECTICUT WELL COMPLETION REPORT DO NOT FILL JN
WATER COMMISSION
317 STATE OFFICE BUILDING This report must be completed and submitted to STATE WELL NO,
HARTFORD 15, CONN. State Water Commission no later than 30 days OTHER N0. .......„....„„.....,.....
after completion of well.
WELL
OWNER
WELL Name Street Address / City or Town
DRILLER:�
Name
treet Address City or Town
PROPOSED USE OR USES (check):
j�Domestic d Irrigation ❑Stock (]Municipal 0Industrial [-]Test Well
CASING DETAILS PUMPING TEST WATER LEVEL SCREEN DETAILS
(measure from land surface)
LENGTH: FEET DURATION: G�^`� �L / OURS STATIC: y a FEET -MAKE: --�
SLOT
DIAMETER: INCHES PUMPING RATE: l� G.P.M. WHEN PUMPING: /f FEET LENGTH: FT. SIZE
KIND: DIAMETER: IN.
WELL LOG
DEPTH FROM Give details of formations penetrated, such as: peat,silt,sand,gravel,clay, hardpan,shale,stone,rock. Include size of gravel
GROUND SURFACE (diameter)and sand (fine, medium,coarse),color of material, structure (loose, packed,cemented, soft, hard)
FT.to FT.
Q FT.to FT. � ---
G1 FT.to FT. /f -
FT.to FT. f i j
FT.to FT. F t Utz v� � :Y ll�
FT.to FT.
FT.to FT.
FT.to FT.
FT.to FT.
FT.to FT.
FT.to FT.
FT,to FT.
FT.to FT.
FT.to FT.
FT.to FT.
ti r
DATE WELL WAS COMPLETED: � S DATE OF REPO - -^ W �D fl>'_
WELL DRILLER
(Signature) '
CERTIFICATE NO. --__
LOCATION OF WELL: TOWN OF
SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
DIAGRAM SHOWING LOCATION OF WELL ON PREMISES: rg k
6/2
1 ?S=
0
ROUTE DIRECTIONS FOR REACHING WELL SITE FROM HARTFORD: