HomeMy WebLinkAbout2015-7-14 - 125 Miller Road - Well ReportsPERMIT NUMBER~-i ifCPR-8 Rev.7/95 i)STATE OF CONNECTICU
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILING PERMIT
l 65 Capitol Avenue,Hartford,Connecticut 06 1 06w
1'I £1 ’.(Town)(Sheet)(Lot Number)DATE
m 4—I.“.a a z;i n 3
INDIVIDUAL
OWNER'S ADDRESS
LOCATION OF WELL
OWNER OF WELL
BUILDER D 0TH%R (Specify)
location of Iot to at least two roads Well location on to and to house (if present)
Indicate North
Xm
x.i e Q;
Approximate number of feet from well tonearestsourceofpossiblecontamination:ewe r .i te
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 tilled in and it has been counter-signed by
the Director of Health or his agent.APPLICANT (Signature)>APPLICANT'S ADDRESS REGISTRATION NO.or:D’s—a Iii r,vv”Z
q;-34
BY (Town Health Officer or Agent)DATE
f \f
SCANNED
i t
DIRECTOR OF HEALTH
T
L
\
XI LCL LI’:J “.1 ‘L:jtcr Ju .J1
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST
USE OF ESTABLISHMENT “I WELL People being
served.
WELL PUBLIC INDUSTRIAL AIR OTHER
I
SUPPLY CONDITIONING (SPeCiIY)
SKETCH OF WELL LOCATION
I Locate well with respect to at least two roads,showing distance from intersection and front of iot
CPR—9 Rev.7/95 Do NOT fill in
STATE WELL NO.STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILLING COMPLETION REPORT
1 65 Capitol Avenue,Hartford,Connecticut 061 06
OTHER NO.
LOCAL DIRECTOR OF HEALTH
ADDRESS
1 k '3’
LOCATION .(No.&Street)
OF WELL Z:”
Y DOMESTIC BUSINESS
PROPOSED ESTABLISHMENT
USE OF WELL§PUBUC INDUSTRIAL AIR
SUPPLY CONDITIONING
DRILLING ROTARY COMPRESSED CABLE OTHER
EQUIPMENT AIR PERCUSSION PERCUSSION (Specify)
§
CASING LENGTH (feet)
DETAILS ‘2 DIAMETER (inches)WEIGHT PER FOOT
1'T?g THREADED D WELDED
DRIVE SHOE
YES U Nov
WAS CASING GROUTED?
YES U No
YIELD TEST 'BAILED PUMPED COMPRESSED AIR HOURS YIELD (GPIII)
$’1‘.
MEASURE FROM LAND SURFACE -STATIC (Specify feet)
:5e E
DURING YIELD TEST (feet)
3 ,3 fi'
Depth of Compleled We]!in feet
3 ’(d :3
SCREEN
DETAILS
MAKE LENGTH OPEN To AOUIFER (feel)
SLOT SIZE DIAMETER (inches)IF GRAVEL
PACKED:
Diameter ol we"
including gravel pack
(inches)
GRAVEL SIZE (inches)FROM (feet)TO (feel)
DEPTH FROM LAND TO SURFACE g
FEET TO FEET
FORMATION DESCRIPTION Sketch exact Iocation of well with distances,to at least two
permanent landmarks
‘RE.
;”it
list belowIfyieldwaswFEET
tested at different depths during driiiing,
GALLONS PER MINUTE
%
DATE WELL COMPLETEDV"-"la {’1 Q}
PERMIT No,
T:a ‘7 1 31
REGISTRATION No,DATE OF REPORT
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