HomeMy WebLinkAbout2020-7-9 - 1400 Main Street - Well Completion ReportCPR—9 Rev.7/95 Do NOT flll In
STATE OF CONNECTICUT STATE WELL NO,
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILLING COMPLETION REPORT
450 Columbus Blvd.,Suite 901,Hartiord,CT 06103
OTHER NO.
LOCAL DIRECTOR OF HEALTH
LOCATION
OF WELLE
(No.&Street)(Town)(LotNumber)
i ;O Egg?¢u4 “a;In w w av$v g v
OWNER NAME
,;)4 £3;3253*,5},‘.’3‘Q‘a;g 1E V:n
ADDRESS
3'..:’4'a;..,i i -u
PROPOSEDUSEOF WELL
E
DOMESTIC BUSINESS FARM TEST
ESTABLISHMENT WELL
PUBLIC INDUSTRIAL AIR OTHER
SUPPLY CONDITIONING (Specify)
DRILLINGEQUIPMENT
ROTARY COMPRESSED CABL OTHER
AIR PERCUSSION PERCUSSION (Specify)
CASING
D %AILS
YIELD TEST
LENGTH (feet)
$3 :1.
DIAMETER (inches)
W a WEIGHT PER FOOT
I ‘;THREADED D WELDED DRIVE SHOE
YES D No
r WAS§YEs
CASING GROUTED?
B No
-BAILED U COMPRESSED AIR HOURS YIELD (GPN)
Iv
WATERLEVEL
MEASURE FROM LAND SURFACE -STATIC (Specify feet)
‘
DURING YIE_D TEST (feet)
3 I:
Depth of Completed Well in feet
SCREEN
DETAILS
MAKE
Li,iJaiiiégE uni
LENGTH OPEN TO AQUIFER (feet)‘é
SLOT SIZE DIAMETER(inches)i IF GRAVEL-PACKED:IIncludingiameterof
gravel
wel—
pg(inches)
GRAVELSIZE (inches)
>2
FROM (feet)r
e:
To (feet)
3 {is
DEPTH FROM LAND TO SURFACE
FEET TO FEET
FORMATION DESCRIPTION Sketch exact Iocation of well with distances,to at Ieast two
permanent landmarks
«A ..,a L t
i
.I
J e
-
El I
If yield was tested at differentdepths during drilling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED
i ,
PERMIT NO.
-’;f}?
REGISTRATION NO.DATE OF REPORT
if?‘I If
WELL DRILLER (Signature)
PERMIT NUMBER
CPR—8 Rev,08/17
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
Locate
location of lot to at least two roads Well location on to and to house (if present)
Indicate North
ill
Approximate number of feet from well to
nearest source of possible contamination:
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.
AP PLICANT (Signature)i APPLICANT’S ADDRESS REGISTRATION NO.
BY (Town Hea/th Officer or Agent)
APPROVED REJECTED
REMARKS
DIRECTOR OF HEALTH
450 Columbus Boulevard Suite 901,Hartford,Cor%;§ecticut 06103
T‘OCATION OF WELL (Srreet)(LotNu/nber)DATE
OWNER OF WELL
INDIVIDUAL B BUILDER a OTHER (Specify)
OWNER'S ADDRESS §
§-Est No.of
PROPOSED
USE OF
WELL
D DOMESTIC E BUSINESS D FARM D TEST
ESTABLISHMENT WELL
AIR
People being
served.
PUBLIC D INDUSTRIAL CONDITIONING D (SPeCIfY)
OTHER
SUPPLY
SKETCH OF WELL LOCATION