HomeMy WebLinkAbout2016-11-25 - 219 Lawrence Road - Well Completion ReportCPR-9 Rev.7/95 Do NOT fil!in g
LOCAL DIRECTOR oF‘HEALTH
.,STATE OF CONNECTICUT STATE WELL NO.
D§PARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION OTHER NO.WELL DRILLING COMPLETION REPORT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION
OF WELL vim
(No,&Street)(Town)(LotNumber)
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OWNER NAME ADDRESS
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PROPOSEDUSEOF WELL
DOMESTIC BUSINESS FARM TEST
ESTABLISHMENT WELL
PUBLIC INDUSTRIAL AIR OTHER
SUPPLY CONDITIONING (Specify)
DRILLINGEQUIPMENT
ROTARY a COMPRESSED CABLE OTHER
AIR PERCUSSION PERCUSSION (Specify)
CASINGDETAILS ,
LENGTH (feet)
%av
DIAMETER (inches)WEIGHT PER FOOT D THREADED D WELDED DRIVE SHOE
D YES D NO
WAS CASING GROUTED?
D YES D NO
YIELD TEST BAILED P UM PED CONTPRESSED AIR g 'HOURsg YIELD (GPN)
WATERLEVEL
MEASURE FROM LAND SURFACE -STATIC (Specify feet)DURING YIE_D TEST (feet)Depth of Completed Well in feet
SCREEN
DETAILS
MAKE LENGTH OPEN TO AQUIFER (feet)
SLOT SIZE DIAMETER (inches)IF GRAVELPACKED:
Diameter of wellinciudinggravelpack(inches)
GRAVEL SIZE (inches)FROM (feet)To (feet)
DEPTH FROM LAND TO SURFACE
FEET TO FEET
FORMATION DESCRIPTION Sketch exact location of well with distances‘to at least two
permanent Iandmarks
‘x
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If yield was tested at different depths during drilling,list beiow
FEET v ‘t.r GALLONS PER MINUTE
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HEALTH DEPT.
DATE WELL COMPLETED PERMIT NO.REGISTRATION NO,DATE OF REPORT WELL DRILLER (Signature)"{f