HomeMy WebLinkAbout1976-5-15 - 1609 Main Street - Well Completion ReportPERMIT NUMBERSTATEOFCONNECTICUT
WELL DRILLING PERMITWELL6RILLINGBOARD”WM-4 11-69 '33881
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
DAT Egffx;z3}/?Xg(Lat Numb er)#7(Street)M26!fM/A/s 7’
7a sage/g
LOCATION OF WELL (Town)smirk {Aim/960,5
OWNER OF WELL I
E/EUILDER xéz f Mwn/a“D OTHER (Specify)
OWNER'S ADDREss
7WDINDIVIDUAI.
Locafe we"with respect To at least two roads,showing disfance from intersecfion and from of lot
-Well Iocation on loT and To house (if present)LocaTion of lot To at least two roads
Indicate North $3;\pg"
I $4.)?ME $5
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57’5wu{’I?”A,°
25’”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
must be sent to the the Board and the Water Resources Commission on the form provided by the
REGISTRATION NO.Ere/LA é a
DATE
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2 -DIRECTOR OF HEALTH
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PROPOSED
0;?
gwmsm BusmgssESTABLISHMENE D FARM 1-551-i
WELL
Est.No.of
People being
served.USE OF AIR OTHER .
WELL D PUBLIC [j 'NDUSTRIAI CONDITIONING D (specify)SUPPg
-SKETCH OE WELL LOCATION g;
CAL DIREC§OR OF HEALTH
WELL COMPLETION REPORT STATE OF CONNECNCUT
WDB~5 12-69 REV.9-71 WELL DRILLING BOARD
State Office Building
HARTFORD,CONNECTICUT O61 15'
Do NOT fiH inm
OTHER NO.
OWNER NAME w
if Swag g’TV?,E 2g .
ADDRESS
.g:
LOCATION
OF WELL
(No.&Street)(Lot Number)
g.
PROPOSED
USE OF
WELL
BUSINESS
ESTABLISHMENT D TEST WELLDOMESTIC
SUPPLY
PUBLIC B lNDusTRIAL
AIR
CONDITIONING D OTHER
(Specify)
DRILLING
EQUIPMENT
.CABLE §OTHERBROTARYPERCUSSION(Specify)
CASING
DETAILS
LENGTH (feet)
§§;3
DIAMETER (inches)WEIGHT PER FOOT
BYKTHREADED D WELDED
DRIVE SHOE
YEs E No
WAS CASING GROUTED?
W5 NO
YIELD
TEST
HOURSDBAILED[j PUMPED 'COMPREssED AIR
§
YIELD (G.P.M.)
;&1§€§
WATER
LEVEL
MEASURE FROM LAND SURFACE—STATIC (Specify feet)DURING YIELD TEST (feet)ewe Depth of Completed Well
in feet below Land surface:R)1 w
SCREEN
DETAILS
MAKE LENGTH OPEN TO AQUIFER (feet)
SLOT SIZE
§
DIAMETER (inches)IF GRAVEL‘PACKED:Diamefer of well including
gravel pack (inches):
GRAVEL SIZE (inches)FROM (feet)TO (feet)
DEPTH FROM LAND SURFACE
FEET to FEET FORMATION DESCRIPTION Sketch exact Iocafion of well with disfances,to af least
two permanent landmarks.
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§
If yield was tested at different depths during drilling,list below
FEET GALLONS PER MINUTE
‘22
DATE WELL COMPLETED PERMIT NO.REGISTRATION NO.
L1 “é:
DATE OF REPORT WELL DRILLER (Signature)T§
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