HomeMy WebLinkAbout2003-7-31 - 210 Avery Street - Well Completion ReportCPR-9 Rev.7/95 .
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADES DIVISION
WELL DRILLING COMPLETION REPORT
165 Capitol Avenue. Hartford, Connecticut 06106
Oo NOT fill in
STATE WELL NO.
OTHER NO.
OWNER
NAME I ADDRESS
JOSEPH CITING 1.33 CLIFFWOOD DR., SO. WINDSOR -CT 0607
LOCATION
OF WELL
(NO- & Sfmel) (T ) fla IY11mber)
210 AVERY STREET SO.-WINDSOR
PROPOSED
USE OF WELL
DOMESTIC BUSINESS FARM
ESTABLISHMENT
a SUBL IC Y INDUSTRIAL AIR DITIONING
-TEST
WELL
OTHER )
DRILLING
EQUIPMENT
ROTARY COMPRESSED CABLE OTHER
® AIR PERCUSSION PERCUSSION 0 (Specify)
CASING
DETAILS
LENGTH (feet) OtAMETER (lines) WEIGHT PER FOOT
20 6 17#
DRIVE SHOE
THREADED � WELDED n YES ❑ NO.
�iL
WAS CASING GROUTE07
Q YES ❑ NO
YIELD TEST
® BAILED [] PUMPED
� COMPRESSED AIR "OURS
4
YIELD (GPM)
1 3
WATER
LEVEL
MEASURE FROM LAND SURFACE - STATIC (Specify feet)
30
DURING YIELD TEST (feel)
545
Depth or Completed Wep in feet
545
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AOUIFER (feel)
SLOT SIZE
=3)
IF GRAVEL
PACKED:
Diameter of well GRAVEL SIZE (inckae)
'vitluding gravel pack
(irrhsa)
FROM peer)
TO {feeq
DEPTH FROM LAND TO SURFACE
FEET TO FEET
FORMATION DESCRIPTION
Sketch exact locatforl of well with distances, to at least two
permanent landmarks
0
9
SAND & GRAVEL
We'll
ell
gat
qa
a�
9
545
RED SHALE
If yield was tested at different depthis during drilfinp, Ilst below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT NO. REGISTRATION N0.
7/22/03 220070 T102
DATE OF REPORT
L RIL gna e}
JOHN M . DPPFORD'Qr"
4
AGENCY
PERMIT NUMBER
CPR-0 Rev. 7195
STATE OF CONNECTICUT 220070
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADES DIVISIONy�
WELL DRILLING PERMIT ti l'T.OF LICENSING
jS Capitol Avenue Hartford, Connecticut 081 6 A cj 33
f14,0 r 1 /� __ �/�° y �n�t koG - b
LOCATION OF WELL 6010—) (strew) I_C0
I1 ma"ber) I __ UAI t
OWNER Of WELL 1
ElINDIVIDUAL ILDER OTHER (Specify)
OWNER'S ADDRESS I
CM. na. or
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
SUBLICPPLY OTHER
S INDUSTRIAL CONDITIONING I
�^ SKETCH OF WELL LOCATION
nearest source of possible contamination: d / I
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
Asaurces 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
/t4b Director of Health or his agent.
BY [Town HeanhAOfficer or Ap ty DATE
PROVED ❑ d CTED
REMARKS
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION