HomeMy WebLinkAbout2008-7-24 - 161 Beelzebub Road - Well Abandonment Completion8 STATE OF C' rNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADLS •-
WELL. ABANDONMENT, VERIFICATION OF �A'ORK C01113LETED
111'uL:&d!L'9L fcd!Q! (:ii: All procedures used to abandurl a well shall I'ollo►►• regulations established under
tiecricsrr 25-128-56 and 25-128-57 of the St,lte of Corineeticut Well Drilling Board Regul;stions (see attaeh-
nlcn[}. '1'lrese regliltrtiotss require that a registered well drilling contractor pes-1'orm the work.
For \vater supply wells attach completed form to Well Permit. For non -water supply wells attach sketch
of )wcll I=Ition to cornpleted form. Distribution: Department Of* Consumer Protection, Department of
1'nvirunrneot�rl Protection, Property Owner, Well Drilling Contractor, Local Director of Health.
1�'t:l! ir�fclrEiiari(rr::
Date worl: completed: _�7= Z
— g
Name 4t UN'nl'1': na"cm, �ar�IA\)Pn C Q-r\ ,%r,— _ r . . . , . ► '• _ _ 1�
Address
I OCMi011 of well (if different from above):
1'Ype of well (drilled, point, dugs et
c.),r. Z-1�--- .. Depth
Diasnerer of well: �
Length of casing: _
WorI: diti:ils anil u# jer inf'oi motion: - - -
N,irrre of rebistei'ed well drilling contractor
performing work:
Registcreil well ilrillinb corrtraetor•'s license type & #: W1-# Ll d�
W3-#
Materials Used: amount of Sand
atnount 311d tyPe(s) ol•grout
Description of work complete([:
drilling contractor)
165 C:rhitul Avenue, Fkrtfal'd, COnflecticUt 06106-1630
Fax: (860) 566-7/630 * 'I'DD: (860) 566-1547
�n ,Afjirrnatit? ;IclioillEqual 0pp01111nih1 Ernploycr
I N
P K I. ; LJ L. C1 (-)jN �; j,' � � I � 'I ', I!- L L A 11P-A 1\4 1'.) 0 IN I\ L L T
1111'_12 I" LI I : It Ii U I I-N 0 'to I 1, I, I( Slit t U LVt,U II U i CS)
1, LJ (I It, I I,) I I'
I ; , L) l I ) t I I. L:%:. m' k:()Il (;Lill i 11:11 it)rl ()I— pollitrion col'-1-01111d Water rescitirces.
(,III) by ;l rv" isfered wul-I driller. 'I'lle f-egisTered well cl I-ij Jill-
vsIminsible Cor cu I)) I)li;i nev N,i i rh rho proced tire Dt' lib.mdon-
1m:111 IIr;-Illll ;l it thol-i o. 0 1' HSU ;I I)II Sidon Ment of the well.
I 'I k 17 c I I I i' -.1 b i I 111. 1 C, I I I I I V I I I
�.c L I I Li jJ 11 111 111 ally \Y; I I L' I- WV U I' I) I I I t- I- Ij 0 to I' lvc I I the 1) 1-0 1 ) e r p 1-(:j c vd I I r e : I fl (I ni o te r io Is s 1) it I I be used
W 11 1. l';l ,fij(:e Ny;j (V I., CiI.0 LI Ia rioll (I t* N1,;l tel, between or "IfflOrIc, Pro-
CL)lIWIIIiII;IriUIl 01' polltiliul) of ground N% resources.
CAII tj I 1l:111purfIrYrib-midim Illuil I L) r d i3I,:UIl (III li:OICLI Of the Ilse (A;I it), well, 1 lie well shAI be sel-ded widl -;'I
:Is pruvided by Section 2-5-1:S-4_2.
-ii.) I
iLb;iI'1LI0jIIIICjIt II,IIIo ;I C11101-111C SOILICi011
130 etplivAelif to -).-) (111;11,ts oilbleach 2.25"X, ;ivoiililble
,500 1
1HIJILLI-ed thil i)—three (33-3) I-ett of six (6) 11112il dilILTICIel' Well,
Lic checked fi'lj I I I I;IIljI to tl)e ellLiI.C, dept'll of the hell before if is,c2l . Iccl,.t(j insure aa-.aIjisr the
oI).SLrlIL.(i0I1 HIM will 61(cl-I'vre wilh Up I el-MIDI'ls,
III,: 1%cll bul-C sliAl be filled -.1lid scaled Iv'"l itlly of IlIkIleri-Als: he:ii cement grout, S;1nd Cement grout,
L)CI.L,j.jjL,: L:hY �I-Ujll, Ur �.Illkf clay or belicollitv CeLlIC.Il't gI,()IIi.
IcI_ ill M1;1111 be pljlcecl in SlIell RkN),-8), tt) voids in the: urour or clilli-iion ol' the grout.
ill ') cu - 11solidatt'd ruck I'U 'Ah.1I to It, mily be filled jyjrjj 111le s:in(I in the zone or zones of collsoli-
I'lic h)p (I]' [lie S;III(l fill Shall be ;II least: tell (10) feet below the button-[ of the casino, and [he reni:iining por-
ShAt be filh-d will) any (31' 11"? (11:11CIJ;IIN SIJVL'Il_11e(l in stibsc-c[ion (e).
I.,M \lClt )I- bore shall be ;ib;Ijj(JuIjuo_I in sjI(:Il 11 111
III IN'livi 1jr Ailliel' that j[ LlUeS It(.)( beC0111V it channel for III(-- vertieitl
uIllur Ijut.ible. ii
1 1, c v Ij .\ --ts I v (lIz. 1) us.,
11 OA (Al wells will) k:;jSjII-S
. 1JI'e-'-)ks, :-Md 0'�Jcndjitoj belwi the pmable ground wilrcr
Nyifll ;I NNI:lEti- [i!lllt e;Il) m
or wcltlt it phav_
J li L)f1Ib:i,fIdL)IIIIlL:lIt of "It! tlIU (L)l) L11 die CiI.Sill- or Irutic materkti mAy be wminared a[ leasr
Will- (.4j icel bulull. [lie UY0IIIILI stir]"ICO,
A1:11. 21, 1,)93)
-Sk;.�Cdl liticatiull 01' lyejj NN'itit (lis lit"cus to - all lc*lisr two purtniment iandmarks
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CPR-8 Rev. 7/95 PERMIT NUMBER
STATE OF CONNECTICUT 243247
p� s� DEPARTMENT OF CONSUMER PROTECTION
�Eys3 REAL ESTATE & PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue, Hartford, Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
South Windsor 161 Reelzehub ^oad-24-20013
OWNER OF WELL
!1 INDIVIDUAL
BUILDER
❑
OTHER (Specify)
OWNER'S ADDRESS
Dave
Stavens "9arber
Utilities"
P.O. Box
331 Ellington
PROPOSED
DOMESTIC
❑
BUSINESS
FARM
❑ TEST
Est. No. of
People being
USE OF
ESTABLISHMENT
WELL
served.
WELL
❑PUBLIC
❑
INDUSTRIAL
AIR
Abandon
OTHER Well
❑
SUPPLY
CONDITIONING
(Specik)
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 leasl two roads I Well location on to and to house fif oresentl
(a)
Indicate North
rA
ki
t
cc+(y- Rxrj)
r--n
Approximate number of feet from well to
nearest source of p❑ ible contamination-
The undersigned i are t upon completion of the well, a "Well Completion Report" containing construction details. and information required under
Section 25-131 the L
ke General Statutes must be sent to the owner, the Department of Consumer Protection and the Water
Resources C v form provided by the agency. This permit is not valid until all information is filled in and it has been counter -signed by
theAirecty _ Hetint.—____
Joel Stavens D.O. Aox 06 Wi lington 42
•' { H frh Q CE r kgerrq DATE � _
APPROVED ❑ REJECTED �_ O
DIRECTOR OF HEALTH