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STATE OF CONNECTICUT STATE WELL NO
gr DEPARTMENT OF CONSUMER PROTECTION
1 REAL ESTATE&PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
OWNER NAME AppRESS
LOCATION (Na&Street') (Town) (Lot Number)
OF WELL i " `° .1.3_=r
DOMESTIC BUSINESS FARM TEST
PROPOSED ESTABLISHMENT WELL
USE OF WELL PUBLIC D SUPPLY INDUSTRIAL AIR
CONDITIONING OTHER(Specify)
DRILLING Q ROTARY COMPRESSED a CABLE OTHER
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS 4 -� 3 O THREADED � WELDED ❑ YES ❑ NO� O YES ❑ NO
YIELD TEST a SAILED PUMPED Q COMPRESSED AIR HOURS YIELD(GPM)
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feet) DURING YIELD TEST(feet) Depth of Completed Well in feet
LEVEL 45
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(fast) TO(feet)
PACKED: including gravel pads
(inches)
DEPTH FROM LAND TO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
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If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL CO/MPPLETED PERMIT NO. REGISTRATION N0. DATE OF REPORT YVELL DRILLER(SigneTu' )
LOCAL DIRECTOR OF HEALTH