HomeMy WebLinkAbout2008-7-23 - 21 Hillsdale Road - Well Abandonment Completion ReportW1 ATE OF CONNECTICUT
DEPARTMENT OF C<::>/\/5LJMER PRaTECTJON
REAL ES'I‘A’I‘E S;PR(H9ESSIONA L,'X'RADISS '-
WLL‘LL ABANDONMENT,VE1'{II'«"1("‘ATION OF ¥\"C)RI’\'COMPLETED
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1m wlnu supplvwells attach uompleted lorm to W ell Pumlt F01 non watel supply welb attach slxctch01\lcll lDLanon m wmphtul torm Distllbutmn DLpA:tment 01 Consumer P1 ()rLLtlon,Department ollnvnunmultal1’:(mmon l):opcrly Owne Wcll l):llhnO Conn aum local l)”utm of Health.
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m;v-«HxmH hr cmul‘inntml pl‘im‘[u nb.xm1unmunl lining n chlm’mc rsuhuiuu WITH n mi:H COHL‘CJ:mu nfone
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PERMIgT NUMBER
STATE OF CONNECTICUT 2 4 3 L 4 8
DEPARTMENT OF CONSUMER PROTECTION gREALESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
1 65 Capitol Avenue.Hartford,Connecticut 06 1 06
CPR-8 Rev.7/95
DIRECTOR OF HEALTH
LOCATION OF WELL (Town)(Street)(LotNumber)"§outh Windsor 21 Hi l ls§ale DATE
7 -2 3 —0%
OWNER OF WELL
IX INDIVIDUAL BUILDER OTHER (Specify)
OWNER'S ADDRESSMarie westbrook 11 Mountain View Roar}Scuth Wimis-ar
of
beingPROPOSED
USE OF
WELL "
DOMESTIC BUSINESS FARM
ESTABLISHMENT
*Puatlc "“INDUSTRIAL”‘AIR I‘‘v 5"”-‘"
SUPPLY CONDITIONING
Est.N04People
sewed.
-SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
location of Iot to at least two roads Well location on to and to house (if present)
Indicate North o)
{U
,7
if}
y
M
f
L,p,
E
if]l l‘tgcm lg a
.X
Approximate number of feet from well to
nearest source of possibjg‘gontamination:
The undersigned is a ‘-that u n completion
Section 25 131 of .>plement to the
ssion o ,mi u-u...-ded by
m:aget.g
Joel Stavens
of the well,a “Well Completion Report"containing construction details and information required under
General Statutes must be sent to the owner,the Department of Consumer Protection and the Water
the agency This permit is not valid until all information is filled in and it has been counter-signed by
APPLICANT s ADDRESS
/;x 4‘05 thi Utehm i
REGISTRATION NO
/APPROVED REJECTED m W {T H alth Off Agen DA *0
REMARKS
TMF w €€€®
DEPARTMENT OF PUBLIC HEALTH
March 10,2008
Ms.Marie A.Westbrook
11 Mountain View Road
P.O.BOX 1196
S uth indsor CT 06074‘aoo é)\LHbQQ
PUBLIC WATER SYSTEM:Hillsdale Water CO-OP
CLAS‘SIFT‘CAT’ION TYPE:‘Community
TOWN:South Windsor,CT
PWSID:CT 1 32005 1
SUBJECT:PUBLIC WATER SYSTEM CLASSIFICATION (INTERCONNECTION)
Dear Ms.Westbrook:
This letter serves to inform you that the Department of Public Health Drinking Water Section has
recently received updated inventory information regarding Hillsdale Water CO-OP.Since this
public water system is being served by another regulated public water system,the status of
Hillsdale Water CO-OP has been changed to inactive and it will no longer be regulated
individually.
If you have any questions regarding this matter,please feel free to contact the Monitoring,
Reporting and Enforcement Unit at (860)509-7333 or 410 Capitol Avenue,MS#51WAT,P.O.
Box 340308,Hartford,CT 06134-0308.
Sincerely,
Christopher D.Roy
Sanitary Engineer 3
Drinking Water Section
Dr.Gerald L.Schwartz,Director of Health,Town of South Windsor
Telephone Device for the Deaf:(860)509—7191
\\
R0.
410
Box
Capitol
340308
Avenue
Hartford,
-MS #
CT 06134 \DQ/
Apirmative Action /An Equal Opportunity Employer
...~
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§
“—"L:.1
REAL ESTATE.S:PROFESSIONAL.TRADES '-
a
~:&Y~STATE.OF C‘G‘NNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
‘NELL ABANDONMENT,VERIFICATION OF WORK COMPLETED
L’mucdm’es fulluwed:All proccdurcs used to abnnduu n well shall t'oHuw rcgulurions established under
Section 25428-56 nnd 25—12867 of the State of Connecticut ‘Nen Driil‘ing Board Regulatians (sec armch~
man).These regulations require that a rhgistercd we“drilling contractor perform the work.
For water supply wells attach completed form to Wcll I’ermit.For nomwmer supply wells attach sketch
ofw‘cll location to comploted form.Distribution:Department Of Consumer Protection,Department of
Environmental Protection,Property Owuer,Well Drilling Contmctor,Local Director ofHealth.
Well information:
'l’owu:_‘Date work completed:
Nome of Owner:l
Location of well (if different from above):
Type of well (drilled,point,dug,ete.):
O J k Depth ol'wcll:s
Lo H ‘1
Diameter of well:Length ol'cnsing:
Work details and other information:
Name of registered well drilling contractor performing work:
Registered well drilling contmctor’s license type  ~W1—#
Materials USed:amount ofsantl
l.‘
amount and typet's)of grout
l
Desription ol‘worlt complete:c d
olJ we mllj/jl
signed:(well drilling contractor)
'lh5 Capitol Avenue,Hartford.Connecticut UnlO6-lb3t)
Fax:(Still)566-7630 o 'i'DD;(860)Sbo-‘l547
flu Affirmative Aclimt/Emmi ()ppurlimtti/Employer
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”and Imk.1m:tupul the sum!nll :lmll bu ul lcilbl Icn (10;u:cl bclow [11c hultum 0!thc c’
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‘m Any launcii or bur:xhzlll bu nlmmlunud in Such u umuncr (hm H Llucs mu mum]:.n
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UJ/22/ZUI l 1b:58 85Ed295158 STNIENS BROTHERS PAGE 811’62
STATE 0R-r/QQNNEcTICUT
-‘B‘WARTMENT OF CONSUMER PROTECTION
REAL ESTATE .52 momsmONAL maous x
WELL ABANDONMENT.VERlFlCATION OF WORK COMPLETED
1W tyumwd;All procedures used t0 abandon n wen shan :‘onuw regulations established under
gecu‘on 25428—56 mud 25-128-57 of the State ofCaunecticut Wen Driiiing Board Regulations (Sec attach-
meat).These regulations require that a registered wt}!driliing comractor perform the work.
r'ur wmer suppiy wells attach comple‘ed form to Well Permit.For non-water supply weus attach sketch
ofwcu mcznion to commuted fm‘m.Distribution:Dcpm‘iment 0f Consumer Prmectioa,Department of
Environmental Protectiou,Property Owner,Woil Drilling Contractor,Local Director ofHealth.
Ljntéjg Q1 J7 kw“,[Mn §QA’1
NM:oWei!gnformmiug;
'I'uwn:§mm w‘mw;Date wor‘k comioie’t d:.
Fume of Owuur:
Address:
Lucmhm amen (if different from above):3
Type of we]!(drmcd,point,dug,em):O J
\Depth of we”:‘
!Length ot‘casing:Diameter of wen:to H
Work ‘Qggaih and othgjn formation:
Nam:of rcgistrru'!wet!th-iiliug contractor performing work:
Registered weii driiling contmctor’s iicense typo &#:.=W1-#
Materiais Used:amount of sand O
amount and typc(s)of grout ,
Dcscription uf work compieted:
.‘_.£.-.-A“fg ga;$x
__(well (h‘iHing cuntmytur)
N35 Capitol Avenue,Harlfurd,Conuécticut 0(7106Jf230
Fax:(860)566-?630 0 'I’DD:(860)56(95}5+7AuAj}irmariuc Amau /Equui Dppvrluziiq;Euwmycr
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of ul‘m:n‘v“.umtm‘inl .rg’:g:E2'2V’.’C ’é’f‘srxi}“v4““mi““iun nbLmdomnmn ihc w];vi m:casing or grunt n2
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