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STATE OF CONNECTICUT STATE WELL NO.
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE Sc PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION (No.&Street) (Town) (Cot Number)
OF WELL 471
OWNER NAME ADDRESS
DOMESTIC BUSINESS FARM TEST
PROPOSED a ESTABLISHMENT WELL
USE OF WELL El PUBLIC 1:1 SUPPLY INDUSTRIAL CAIR ONDITIONING OTHER(Specify)
DRILLING ROTARY COMPRESSED CABLE OTHER
f EQUIPMENT F 11 AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
THREADED❑ WELDED O YES NO � YES NO
DETAILS '`";
YIELD TEST BAILED El PUMP— El
COMPRESSEDAIR HOURS YIELD(GPM)
i
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well in feet
LEVEL
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
` DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL iameter o we GRAVEL SIZE(inches) set poet)
PACKED: including gravel pack
(inches)
fDEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
I FEET TO FEET permanent landmarks
i
I
3.
I f
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
RECEIVE �
R
HEALTH DEP
DATE WELL COMPLETED PERMIT NO. REGISTRATION NO. DATE OF REPORT WELL DRILLER(Signature) v j .
1 F 1) a
LOCAL DIRECTOR OF HEALTH