HomeMy WebLinkAbout2004-4-21 - 1540 Main Street - Well Completion Report.'I
CPR-8 Rev.7/95
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165 Cao Aéenue.%rt%rd Co
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08 I 06
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OWNER'S ADDRESS
OTHER (Specify)
PERMIT NUMBER
222469
DATE
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RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
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‘PROPOSED -
USE OFWELL
DOMESTIC BUSINESS ‘FARM TESTESTABLISHMENTWELL
PUBLICSUPPLY D INDUSTRIAL AIRCONDITIONING (Sped'v)
OTHER ’
Esl.No.ofPeoptebeingserved‘
SKETCH OF WELL LOCATION
Locate well with respect to a!least two roads.showmg dlslance Irom intersection and front of Iol
location of lot to at Ieast two roads Well location on to and Io house (if present)
Indicate North
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V‘?
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Approxumale
nearest source
number
of posSIbIe
of feet
contammatuon
from well to g (+
The underslgned Is aware that upon completuon of the well a “Well Complellon Report containing construction detalls and Informauon 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 Commrssron on e form provrded by the agency Thrs permrt Is not valrd until all Informatron Is fl!In and It has been counter-srgned by()(n’7APPLICANTSADDRS
WM 5/4mr4wlt 6 (7‘REGISTRATION NO
BY {Town Health OmCer or Agent)DATE
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REMARKS M /”w”M 72 1 L
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
Do NOT Iill in
STATE WELL N0.
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILLING COMPLETION REPORT
I 65 Connecticut 08 I 08
OTHER No.
I 65 Capitol Avenue,Hartford,
OWNER NAME I &ADDRESS
LOCATION
OF WELL
mo.I Street)(Town)(Lo:Number)
Domesnc BUSINESS TEST
ESTABLISHMENT WELL
Puauc D INDusmmL D AIRCONDITIONING
OTHER
(S ‘)SUPPLY
PROPOSED
USE OF WELL
-—"———DRILUNG
EQUIPMENT D ROTARY V COMPRESSED CABLE OTHER’A AIR PERCUSSION PERcussION (Specify)
CASING
DETAILS
LENGTH (m1)’
.
I‘.
I ‘-
DIAMETER (mam)u wEIEHT PERTOOT/Z Lb -g THREADED D WELDED DRIVE suoeaYesU uo-
wAs CAsme Gaou‘rEo?
Ea Yes D no
YIELD TEST D amen Puurso conPnEssen AIR Houas t View (G
WATER
LEVEL
MEA3URE mom LAND suaF’Acs -STATIC (Spam teen5c)ouams YIELo TEST (IeienQ90
oepm of :ompMaa Wan in teatas!
SCREEN
DETAILS
MAKE LENGTH OPEN To AouuFER (mt)
SLOT SIZE DIAMETER (inches)IF GRAVTEmom);Diamete!of wellInducingwuvelpad(m)
GRAVEL sIzE (was)FROM (int)To (I991)
DEPTH FROM LAND To SURFACE
FEET TO FEET
FORMATION DESCRWEON Sketch exact Iocation of we"with distances.Io at least Iwo
permanent Iandmalks
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QO g u¢4¢yC L m VI
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If yieid was tested at dmerent depths during dtilling.list below
FEET GALLONS PER MINUTE
I q QO WII.l “
'OATE wELL cOMPLETEnE77~o FERNT—?NOA2449 ==’REOISTRATION NO.I4é 'DATE OF REPORTV—EMW wELL o
-
IS‘Iur
‘L 2%.
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AGENCY
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