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WATER RESOURCES COMMISSION This report must be completed and submitted State Well No.
317 State Office Building to State Water Resources Commission no later -"
Hartford 15, Conn. than 30 days after completion of well. Other No. _
WELLOWNER
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/ l Name 4 Street Kid re ity an nWELL
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DRILLER/ _.�
Name Street Addreas
Pity and Town
PROPOSED USE OR USES (Check):
Domestic Farm Business
❑ ❑ Irrigation ❑ Establishment ❑ Municipal ❑ Industrial ❑ Test Well
CASING DETAILS YIELD TEST WATER LEVEL SCREEN DETAILS
[� Sailed (measure from land su ace)
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Length: Feet ❑ Pumped Hours Static: f" Feet Make:
When Bailed � Slot
Diameter: Inches Yield: ,f G.P.M. or Pumped &'! Feet. Length Ft. Size
Kind: Diameter: In.
TOTAL DEPTH OF WELL __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.to 134 ft,gray
granite.
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FT.to ,,tj FT. ✓' /
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FT.to FT. h,
FT.to FT. vl
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.
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Date Well Was Completed: / f � "I Date of Report
Well Driller
Certificate No.-.--
LOCATION OF WELL: TOWN OF
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SKETCH SHOWING LOCATION OF PREMISES IN TOWN:
(Show distance and direction from road intersection or other landmark.)
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DIAGRAM SHOWING LOCATION OF WELL ON PREMISES:
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ROUTE DIRECTIONS FOR REACHING WELL SITE FROM NEAREST CITY OR VILLAGE CENTER:
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