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CPR-9 Rev.7195
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STATE OF CONNECTICUT STATE WELL NO.
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION OTHER NO.
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
OWNER NAME ADDRESS
LOCATION (No.a SfreeV (Town) (Lot Number)
OF WELL
DOMESTIC El ESTABLIS HMENT FARM a W LL
ST
PROPOSED
USE OF WELL PUBLIC a SUPPLY INDUSTRIAL AIR OTHER
CONDITIONING (Specify)
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT ElAIR PERCUSSION PERCUSSION El (Specity)
CASING LENGTH(feet) DIAMETER(inches) WEIGHT PER FOOT DRIVE SHOE WAS CASING GROUTED?
DETAILS j'A) THREADED WELDED
0 ❑ YES ❑ NO• ❑ YES ❑ NO
YIELD TEST aBAILED a PUMPED 0 COMPRESSEDAIR HOURS YIELD(GPM)
WATER MEASURE FROM LAND SURFACE-STATIC(Specify feel) DURING YIELD TEST(feet) Depth of Completed Well in feet
LEVEL <a
MAKE LENGTH OPEN TO AQUIFER(feet)
SCREEN
DETAILS SLOT SIZE DIAMETER(inches) IF GRAVEL Diameter of well GRAVEL SIZE(inches) FROM(feet) TO(feet)
PACKED including gravel pack
(inches)
DEPTH FROM LANDTO SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances,to at least two
FEET TO FEET permanent landmarks
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SOUTH HINIDSOR
1-11-AL11-1 DEPI.
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If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
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DATE WELL COMPLETED PERMIT N0. REGISTRATION NO DATE OF REPORT WELL DRILLER(Signature)
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LOCAL DIRECTOR OF HEALTH