HomeMy WebLinkAbout1974-10-21 - 11 Mountain View Road - Well Completion Report@JEKE
\NDB-5 12-69
G‘NNER
LOCATEON
OF WELL
’i’ATE OF CONNECTNUT
REV.9-7]W’ELL DRELLING BOARD
{;§52{;?LE“F:L¢N 55$‘RE?wR?n
STate Office Building
HARTFORD,CONNECTICUT 061 15
NANxE ADDRESS/..‘
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Do NOT fill in
STATE WELL N0.S w f 7 I
OTHER NO.
(No.&Streef)(Town)(Lof Number)ETH+t
‘~1/f i é:w :§.1 3 '
‘L\C-.Ji’.>§fi'
PROPGSED
USE CF
V‘e’ELL
V iDDOMES‘HC BUSINESS
ESTABLI$HMENT D FARM D TEST WELL
SUPPLY
PUBUC D INDUSTRIAL AIR
CONDITIONING D OTHER
(Specn‘y)
FEE’TTLTNGLGbTPMENT D ROTARY AIR
COMPRESSED
PERCUSSION
CABLE
PERCUSSION B (SpeCTfy)
OTHER
LENGTH (feeT)DIAMETER (inches)WEIGHT PER FOOT
THREADED D WELDED
D§§ZHOEBNO WAS CASING GROUTED?
YES NO
Y 5L3
TEST
HOURSDBAILEDDPUMPEDDCOMPREssEDAIRI
YIELD (G‘P.N'..)
MEASURE FROM LAND SURFACE—STATIC (Specify feef)‘DURING YIELD TEST (feet)
i
Depfh of Complefed Well
in fee?below Land surface:
SCREEN
DETAILS
MAKE LENGTH OPEN TO AQUIFER (fee?)
SLOT SIZE DIAMETER (inches)[F GRAVEL
PACKED:Diamefer of well including
gravel pack (inches):
GRAVEL SIZE (inches)FROM (fee?)TO (feet)
DEPTH FROM LAND SURFACE
FEET To FEET FORMATION DESCRIPTION Skefch
Two permanenf
exacf Iocation
Iand marks
of Vie II with distances,To at leasf
I
K
If yield was ‘res’red af differen?depfhs during drilling,Iisf below
FEET GALLONS PER MINUTE
DATE VVELL COMPLETED ‘PERMIT NO.REGISTRATION NO.
i)’l
VI
DATE OF REPORT
Lf/lg,'
WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB-4 11-69 WELL DRHLuNG PERMIT 2 2 6 g 8
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL (Tow (Street)(Lot Number)DATE
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OWNER OF WELL
E’INDIVIDUAL D BUILDER D OTHER (Specify)
OWNER'S ADDRESS
2 d2 z {6\j4u’M%y¢o€
Est.No.of
PROPOSED
'BUSINESS
ESTABLISHMENT
'”T '
People being
USE OF Sel'VeAIROTHERWELLPunuc
SUPPLY E INDUSTRIAL D CONDITIONING D (specify)
SKETCH OF WELL LOCATION
Locafe well wiih respect To af Ieasf Two roads,showing disfance from intersection and front Of Iot
Location of Iot to at least two roads
5k §5N
EARM
':D’TEST
WELL wwwgx;v
Well Iocation on Iot and tO house (if present)
M Wé/
Si:TE ti:
Wé/y«/
’":/77~
/7V7’
Wi#
A5
é/é/
Approximate number of feet from well to 7d "
nearest source of possible contamination:
The underSIgned Is aware that Upon completlon of the well a ”Well Completion Report"containing constructlon details and mformatlon 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 prOVIded by the
ma on Is filled In and It has been counter signed by the Director of Health or his agen t
D REJECTEDAPPROVED
REMARKS
//j
”ATEQ R
DIRECTOR OF HEALTH
3