HomeMy WebLinkAbout1976-4-26 - 1624 Main Street - Well Completion ReportWELL DRIEuNG BOARD .STATE OF CONNECTICUT I PERM”NUMaER
33881.WELL DRHJJNG PERMIT
STATE OFFICE BUlLDlNG,HARTFORD,CONNECTICUT 06115
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ONSWER’ADRESDS
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PROPOSED
uss OF
WELL
Locaie Well with resect to at least two roads,showing distance from intersection and front of lot
a.lNDusmAI.CONDITIONING
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Well Ioc'ation on Iot and to house (if present)
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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 Board and the Water Resources Commission on the form provtded by the
Beard.This pe mit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent.
REGISTRATION NO.t’
_.VM‘REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
LOCAT OFWLL ()7/My MW
ND
N
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BOARD
WELL COMPLETION REPORT ‘srATE OF CONNEctIcu‘r '
wow I2¢9 Rev.9—71 ‘.~WELL DRILLING BOARD
$fate Office Building
HARTFORD,CONNECIICUT 061 15
Dd NOT fill in
$TATE WELL No.
OTHER No..
OWNER NAME .i l m ‘.011 .
ADDRESs
l 25'.E d cu i I n 8+.Sou-W Lu'md sar
IOCAIIONorWELL (No.&Street)Clown)(Lot Number)lam!main 3+.'Sou-Ha U)Ln d5 of I
PROPOSED
USE OF
WELL
EUSINEss
ESTABLISHMENT -'D TEST WELLDOMESTIC-FARM
PuaLIc
SUPPLY D INDUSTRIAL '
‘AIR
CONDITIONING D OTHER
(Specify)
DRILLING
EQUIPMENT B ROTARY AIR
OMPRESSED
PERCUSSION
CABLE
PERCUSSION OTHER
(Specify)
CASING
DETAILS
LENGTH (Teen)
l 9 l
.DIAMETER (inches)
6
wEIGHT PER r001 -'[9"{5‘l @THREADED D WELDED
DRIVE SHOEEns DNo WAS CASING GROUTED?
EYES DNO
Lg::1 mm-‘D PUMPED g COMPRESSED AIR ‘-
'.L HOURS E
L/‘-'
YIELD IG.P.M.)‘JO
WATER
LEVEL
MEASURE FROM LAND suRFACE—STAIIC (Speciry teen‘/o DURING YIELD TEST (fear
J50 Depth Of Completed We"
in feet beIOw Land surface:30&
SCREEN
DETAILS
MAKE LENGTH OPEN To AQUIEER (feet)
SLOT SIzE DIAMETER (inches)H:GRAVEL'PACKED:Diamefet of well including
gravel pack (inches):
G R AVEL T SIzE (inches)FROM (feet)To (feet)
.‘DEPTH FROM LAND SURFACE
J FORMATION DESCRIPTION Two
SkeTch
permanent
exact Iocation
Iandmar
Ofkwell
s.
with disTances,To at
LeastFEETIoFEET
o [30
3725 ‘'
'bo-Q.I PW
I
&goé YOJ 2acl<
If yield was Tested at different depths during drilling,list below ~'
v FEET GALLONS PER MINUTE
‘1 I
'ADATE
WELL COMPLETED
..5,14:'1_Lé
PERMITNO..,
3 3
~_
8&l _
REGISTRATION No..
3 ‘i DATE
.
OF REPORT-‘
,.L WELL DRILLER (Signature)I
..
,—‘L.....i.,..
WELL €QMPLEHON REPOR'F 57A“OF CONNECT‘CUT
WDM 12.69 REV.9—71 WELL DRlLLiNG BOAR§
Stam Office Building
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HARTFORD,CONNECTICUT 06115
W l
STATE WELL NO.
OTHER NO‘
OWNER NAME
‘
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ADDRESSi 5K)ch r w QWH":,varc ‘5‘‘.'gr;
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(NO-&Sfreef)(Lot Number)
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PROFOSED
USE GF
WELL
.§?E-T’DOMESTIC_BUSINESS
ESTABLISHMENT D FARM D TEST WELL
PUBLic
SUPPLY B ‘NDUSTRIAL
AIR
CONDITION‘NG D OTHER
(specify)
DRILUNG
EQUEPMENT
CASVNG
DEH‘dLS
D ROTARY
.5 FOMPRE$SEDAmPERCUSSION
CABLE
PERCUSSION ‘i OTHER
(specify)
LENGTH (feet)
£73;gr 'I
DIAMETER
5*;
(inches)!WEIGHT PER FOOT
THREADED D WEIDED
DRIVE SHOE
EYES D No
WAS CASING GROUTED?
VES No
’”hmf?$3.;
WARR
EVEL
'K HOURS YIELD (G.I>.M.)
E BAILED D PJMPEDI N COMPRESSED t AIR i é i w“;3‘
MEASURE FROM LAND SURFACE—STATIC (specify Ieen
£135 i}
DURING YIELD TEST (feel)
ggig
Depfh of Commaed We“
in fee?below Land surface:irigs‘g
"“
$CEEEN
§E TH k LS
MAKE LENGTH OPEN To AQUIFER (feet)
SLOT SIZE
‘
DIAMETER (inc‘h es)
i
JF GRAVEL
PACKED:Diamefer of we”induding
gravel pack (inches):
GRAVEL SIZ E (inches)‘FPOM.(feet)TO (feet)
DE JT H FR?A I.LA k ID 5U R FACE
FEE-T To FEET FORMATloN DESCRIPTION Skefch exacT iocaTIon of we“WITh distances,To af ieasf...
Two permanenf landmarks.
5f}
‘r"?5%
W5}
SEE:.v"$
If yield was tesfed at different depths during driiling,list below
FEET GALLONS PER MINUTE
DATE WELL COMPLETED PERMIT No.REGISTRATION NO.DATE OF REPORT