HomeMy WebLinkAbout2010-10-5 - 1546 John Fitch Boulevard - Well AbandonmentSTATE >OF C(3N,NECTIC’UT
‘(1Q DEPARTNI’ENT OF CONSUMER PROTECTION
REAL ESTATE 6k PROFESSIONAL TRADES :
WELL ABANDONMENT,VERIFICATION OF WORK COMPLETED
géctl;n
in u’udurex
75:178
t‘ulluwu‘l:
56-:md
All
25 178-‘57
p‘rouedurus of
lthe used
St-at-e
to
of
z‘lbandou
(‘Eonnec‘ticut
a well
Well
shall
Drilling
l'olluw rcgul
B-oarid
mum
Regulations
established
(see
undu
z‘ltm‘c'h-
lucm).'l‘l’les;1:6gulations-rgquire that a registered well drilling contractor perform the work.
b‘ur wntcrsupply wells attach completed form to Well Permit.For non-water supply wells .attach sketcll
of well locut'mn to completed form.Distribution:Department of Consumer Protection,Department of
Envirom'nemal Protection,Property Owner,Well Drilling Contractor,Local Director of Health.
Well irxfornmtion:
’l‘own:Soolk w t “at”r Date work completed:
Name of Owner:w ell-lo _1:9“\{ma'k—
Address:f\\v
Location ot‘wcll (ifcliffcrent from above):~$Q/n‘lg E
Typo of well (drilled,point,dug,etc.):i)r i V‘e&,_Depth ofwcll:I
Diameterot‘well:la n Length ol'cnsing:Ho I
Work details and other informntion:w'.I
Name of registered well drilling contractor performing work:36A S+én
Registered wcll drilling contractor’s license type &#z _W'l-#1 a;_W3-#
Materials Used:amount ol'snnd
amount and type(s)ofgrout _g 7 —C &m%”t «mafi—
Q
Description ot'worlt completed:
signed:(well drilling contrz‘ictor)
'lhS Capitol Avenue,Hartford,Connecticut 061064630
Fox;(550)566-7630 o TDD:(860)566.1547
s’iu r‘lf/irmativc Action/Eqtml Opportunity Employer
v—W::,——.
-—
DIRECTOR OF HEALTH
:./’CPR-8 Rev,7/95
i”a?
’§
Vi;
PERMIT NUMBER
2 4 8 6 4 9STATEOFCONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE 8i PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL "(row (Street)(LotNumber)
South Wimisor 1546 Jahin Einch glvé
DATE
1 0 f 27 {1 0
OWNER OF WELL
INDIVIDUAL BUILDER OTHER (Specify)
OWNER'S ADDRESS Ful 1 Line Au to I 545 JO’nn E‘inch Blvd gouth Windsor —,,,L WMEst.No.ofPeoplebeing
sewed.
Abandqned well
PROPOSED
USE OF
WELL
B DOMESTIC E BUSINESS FARM D TEST
5:”ESTABLISHMENT WELL
,RUBLIC y INDusTRIAL v AIR;r OTHER
SUPPLY CONDITIONING (SpeCIfy)7 SKETCH OF WELL LOCATION &
Locate well with respect to at least two roads,showing distance from intersection and front of
location of lot to at least two roads Well location on to and to house (if present)-
Indicate North K/
w
QéIE/v eéa
‘JJ‘I’L u
A¥$Q§fn¢
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is
Section 25-131 of the
Resources I ommissio
t§the Dire r of He I
Ii
aware that upon completion of the well,a “Well Completion Report"containing construction details and information required under
1969 Supplement to the General Statutes must be sent to the owner.the Department of Consumer Protection and the Water
on the form provided by the agency.This permit is not valid until all information is hlled in and it has been counter~signed by
r his agent.
Joel Stevens APPLICANTS ADDRESSRDBox €346 Willington REGISTRATION NO.
4 2
PROVED REJECTED
BY (Town Hea/th Officer or Agent)D /41 DATE
i lee v‘O
i.REMARKS