HomeMy WebLinkAboutWell New 00 Sullivan Avenue WELL-DRILUNG BOARD STATE OF CONNECTICUT PERMIT NUMBER
wDB-a "-69 WELL DRILLING PERMIT 3907
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF (Town) J {Sheet) (Lot Number) DATE
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OWNER OF WELL
❑INDIVIDUAL ❑ BUILDER ❑ 67HER(Specify)
OWNDt'S ODRESS
PROPOSED /NT»771C ❑ BUSINESS TEST Est.No.of
USE OF ESTABLISHMENT
❑ FARM ❑ WELL People being
BLIC
WELL ❑ SUPPLY ❑ INDUSTRIAL served.
AIR OlI{�
❑ 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)
Indicate North
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A. /)
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Approximate number of feet from well to
nearest source of possible contamination: �t�Jwell,
The undersigned is aware that upon completion of a"Well Completion Report" ontaining construction details and information required under Section 6 of
Public Act 659 must be sent to the owner,the Board cnd the--Water Resources Co mmi i n on the form provided by the Board.This permit is not valid until all informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
APPLICA Ignature) PU 'S DDRE REGISTRATION NO.
Y nt) DATE
APP OVED ❑ REJECTED
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RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT
wD6-5 14.69 WELL DRILLING BOARD Do NOT fill in
State Office Building
STATE WELL NO.
HARTFORD,CONNECTICUT 06115
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X OTHER NO.
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OWNER
NAME ADDRESS
'
LOCATION (No.6 Street) (Town (Lot Number)
OF WELL
BUSINESS
'J DOMESTIC ❑ ESTABLISHMENT ❑ FARM
PROPOSED L ❑ TEST WELL
USE OF
WELL PUBLIC AIR❑ SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING (specify)
DRILLING COMPRESSED CABLE
EQUIPMENT I i ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ OTHER
(Specify)
CASING' LENGTH(feet) hAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING ROUTED?
DETAILS C L!I THREADED El WELDED ❑YES ❑NO LYES NO
YIELD TEST ❑BAILED ❑ PUMPED �COMPRESSED AIR HOURS G.P.M. YIELD(G.P.M.J
WATER MEASURE FROM LAND SURFACE feet) DURING YIELD TEST(feet) Depth of Completed Well
LEVEL in feet below Land surface: "Y
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(Inches) IF GRAVEL Diameter of wall 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
FEET to FEET FORMATION DESCRIPTION two Permanent landmarks.
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3 0 ..1�
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If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO, REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature)
v- Y.
BOARD
WELL COMPLETION REPORT STATE OF CONNECTICUT -
WDB-5 12.69 WELL DRILLING BOARD Do NOT fill in
State Office Building STATE WELL NO.
HARTFORD,CONNECTICUT 06115 SW L CF
` tjr t� s OTHER NO. CJ
f 111
NAME y OWNER ADDRESS
ii l 1
T
LOCATION (No. &Street) (Town) (Lot Number)
OF WELL
BUSINESS
PROPOSED u DOMESTIC ❑ ESTABLISHMENT ❑ FARM L_I TEST WELL
USE OF
WELL PUBLIC-SUPPLY El INDUSTRIAL El AIR OTHER❑
CONDITIONING (Specify)
DRILLING f-1 t (�COMPRESSED CABLE OTHER
EQUIPMENT I� ROTARY P AIR PERCUSSION ❑ PERCUSSION Ell (Specify)
CASING LENGTH(feet) DIAMETER(inch es) WEIGHT PER FOOT I ]r' DRIVE SHOE WAS CASING GROUTED?
DETAILS (� L� � , I-' THREADED ❑WELDED ❑YES ❑NO ❑YES ❑NO
HOURS G.P.M. YIELD(G.P.M.)
TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feet) DURING YIELD TEST(feet) rr
Depth of Completed Well
LEVEL in feet below Land surface: l �
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
FORMATION DESCRIPTION Sketch exact location of well with distances, to at least
FEET to FEET two permanent landmarks.
3 �
- D 49
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature)