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Home My WebLink About151 Oakland Road CPR-8 Rev 7I95 PERMIT S `NUMBER STATE OF CONNECTICUT RBER�' '— " DEPARTMENT OF CONSUMER PROTECTION ? REAL ESTATE&PROFESSIONAL TRADES DIVISION _> WELL DRILLING PERMIT 165 Capitol Avenue,Hartford,Connecticut 06106 LOCATION OF WELL (Town) Sliest) (Lot Number) DATE OWNER OF WELL ` INDIVIDUAL BUILDER OTHER(Specify) 1-17) OWNERS ADDRESS ' Est No of PROPOSED DOMESTIC BUSINESS FARM TEST People being USE OF ESTABLISHMENT WELL served. WELL SUPPLY INDUSTRIAL OTHER CONDITIONING (Spec, 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 to and to house(if present) I `��, �'r.�, �:c' 1 U 0 Indicate North I << t ao,c k Oi Approximate number of feet from well to {Q nearest source of possible contamination. /�J The undersigned is aware that upon completion of the well, a"Well Completion Report"containing construction details and information required under Section 25-131 of the 1969 Supplement to the General Statutes must be sent to the owner, the Department of Consumer Protection and the Water Resources Commission on the form provided by the agency. This permit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent APPLICANT(Signature) f APPLICANT'S ADDRESS REGISTRATION NO BY(Town Health Officer or Agent) DATE APPROVED REJECTED REMARKS DIRECTOR OF HEALTH OCCUPATIONAL&PROFESSIONAL TRADES WELL ABANDONAMNT,VERIFICATION OF WORK COIN TLETED Procedures followed: All procedures used to abandon a well shall follow regulations established under Section 25-128-56 and 25-128-57 of the State of Connecticut Well Drilling Board Regulations (see attach- ment). 'These regulations require that a registered well drilling contractor perform the work. For Eater supply wells attach completed form to Well Permit. For non-water supply wells attach sketch of well location to completed form. Distribution: Department of Consumer Protection,Department of Eavironmental Protection,Property Owner,Well Drilling Contractor,Local Director of Health. AXell information: oy,4�ti c 1 n hate work completed: ��/1�X W,1/7 Name of Owner: /91C,Y6 ix1c� r�o Address: �' f �� , ��.� ��cjr—, L Col -�e /06 Location of well(if different from above): Z- Type of well(drilled,point,dug,etc.): (4.r-1 l/to c,� Depth of well: Diameter of well: Length of casing: t 3/ Work details and other information: Name of registered well drilling contractor performing work: Registered well drilling contractor's license type chi#: Wl-# la W3-4 Permit#(if applicable) Materials Used: amount of sand J, �- amount and type(s) of grout (Description of work completed: Signed: (Well IDrilldng Contractor) REGULATIONS FOR WELL ABANDONMENT (Regulations of Connecticut State Agencies) See. 25-128-56: Abandonment of wells, responsibility Any well that is abandoned shall not be a source or cause of contamination or pollution of ground water resources. Abandonment procedures shall be performed or directed only by a registered well driller. The registered well drilling contractor who performs the work of abandonment shall be responsible for compliance with the procedure of abandon- ment of the well,as provided in this part and shall notify the local health authority of the abandonment of the well. (Effective May 21,1993) Sec. 25-128-57. Procedure of abandonment In the event of abandonment of any water well or other type of well the proper procedure and materials shall be used as follows: (a)The well shall be plugged to prevent the entrance of surface water,circulation of water between or among pro- ducing zones,or any other process resulting in the contamination or pollution of ground water resources. (b)In the event of temporary abandonment or discontinuance of the use of any well,the well shall be sealed with a watertight cap or seal,as provided by Section 25-128-42 (c). (c)The well shall be chlorinated prior to abandonment using a chlorine solution with a minimum concentration of one hundred fifty parts per million(150 ppm)of chlorine. This is equivalent to 5.5 quarts of bleach at 2.25%available chlorine to five hundred (500)gallons of water or three hundred thirty-three(333)feet of six(6)inch diameter well. (d) The well shall be checked from land surface to the entire depth of the well before it is sealed,to insure against the presence of any obstruction that will interfere with sealing operations. (e)The well bore shall be filled and sealed with any of the following materials: beat cement grout,sand cement grout, bentonite clay grout,or sand clay or bentonite cement grout. (f) The grout material shall be placed in such a way to prevent voids in the grout or dilution of the grout. (g)Any well constructed in a consolidated rock formation, may be filled with fine sand in the zone or zones of consoli- dated rock. The top of the sand fill shall be at least ten(10)feet below the bottom of the casing,and the remaining por- tions of the well shall be filled with any of the materials specified in subsection(e). (h)Any test well or bore shall be abandoned in such a manner that it does not become a channel for the vertical movement of water or other substance to the potable ground water resources. (i)Deep waste disposal or oil wells with casings free of any breaks,and extending below the potable ground water zones,may be sealed with a water tight cap or welded plate. (j)Upon completion of abandonment of the well,the top of the casing or grout material may be terminated at least four(4)feet below the ground surface. (Effective May 21,1993) SKETCH OF WELL LOCATION Sketch exact location of well with distances to at least two permanent landmarks � 1 � V 0" Indicate North \ orc i -------------