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BOX 10
PERMIT # W- 108 -93
�A O.
WELL COMYLE'flUDI mrIrUni
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADORESS: WN1V1L TAX GRID NUMBER:
25 Venice Rd., Patterson, NY
WELL OWNER
NAME: ADDRESS:
Joseph Grasso, 25 Venice Rd„ Patterson, NY
® PBIVATE
o PueLlc
USE OF WELL
1 - primary
2 - secondary
)a RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /HEAT PUMP O ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 4 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY
ANEW SUPPLY (NEW DWELLING) XMEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 425 ft.
STATIC WATER LEVEL 145 ft.
tt���'
DATE MEASURED 9/1:4/g3' -
DRILLING
EQUIPMENT
❑ ROTARY XQ COMPRESSED AIR PERCUSSION ❑ DUG :� : - -
❑ WELL POINT O CABLE PERCUSSION O OTHER (specify): — ' ��
r-'.
WELL TYPE
❑ SCREENED ❑ OPEN END CASING XXXOPEN HOLE IN BEDROCK O OTHER, :Z! Q
CASING
DETAILS
TOTAL LENGTH _ ft.
MATERIALS: O STEEL O PLASTIC. 64tEE
LENGTH BELOW GRADE ft.
JOINTS: _ O WELDED O THREADS *4R.
DIAMETER in.
SEAL: O CEMENT GROUT ❑ BENTONITE 0OTHER
WEIGHT PER FOOT Ib_/ft_
I DRIVE SHOE O YES ❑ NO
I LIN ER: 0YES ONO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
OYES ONO
HGUAS
SECUNU
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
I DEPTH ft.
WELL YIELD TEST If detailed pumping
METHOD: ❑ PUMPED 1 tests were done is in-
x] COMPRESSED AIR , ! ormation attached?
O BAILED ❑ OTHER ❑ YES O NO
WELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear.
ing
Well
0ia'
Teter
FORMATION DESCRIPTION
p0E
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
lt.
YIELD
gym-
Land
175
42
ar grey granite
425
6 -
300.
12
WATER X04 CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? XC4YES ONO
ANALYSIS ATTACHEM YES ❑ NO
STORAGE TANK: TYPE Diaphragm
CAPACITY 62 GAT,. 17
PUMP INFORMATION
TYPE s ubme r s 1 b 1 e CAPACITY 10
MAKER GOU LDS DEPTH
MODEL j I t.S n f�j2_ VOLTAGr2_3e. HP _4_
WELL DRILLER NAME MILL D R I LL I 16/93
ADDRESS Putnam Avenue SIGN
Brewster, NY R r i 11, r, t
9 NO
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD
REDR ILL
PERMIT #
WELL LOCATION
S r et Addr ss
26� �eni.ce �Zd,
Town Villa a City Tax Grid Number
Patte.rsonp 'New fork
WELL OWNER
Name Mailing Address (Putnam Lake)
Joseph Grasso, 25 Venice 1Zd,t,, Pattersons NY
Private
0Public
USE OF WELL
1 - primary
2 - secondary
zQ RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
O FARM • .0 TEST /OBSERVATION
O INSTITUTIONAL .' „.0 STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED 4 /EST. OF DAILY USAGE_Jgal
E3 REPLACE EXISTING!SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING i3 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
o ri ed we l has Very low yield.
WELL TYPE
00RILLED
O
DRIVEN QDUG :, GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ' ” NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION,.NAME OF SUBDIVISION: NIA
Lot No.
"I
WATER WELL CONTRACTOR: Name MILL 9RILLIN0, INC,. Address: PUTN4M AXENUE
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES xx N0'
NAME OF PUBLIC WATER SUPPLY.,:-. TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: n/ a
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
O ON SEPARATE SHEET
�= t.. 9th, 1993
(date) (sig ature)
Robert Mo Mill, PRESIDENT
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a.Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise-- eontaminate surface or groundwater.
Date of Issue:� 19_- ----"/
Date of Expiration
Permit is Non - Transferrable
3/89
19 Permit Issuing Official
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
"
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