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BOX 10
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a' WELL UUF1YLt"11U1V JAUXUTCl
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* * DEPARTMENT OF HEALTH
—'- - Division'-Of ' Enviionmenfal Health - Service's `
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
,
WELL LOCATION
STREET AOORESS: ToWNIVICLAGAIcIly TAX GRID NuMeEk
Palisades Road Patterson, New York
WELL OWNER
NAME l iaTi Weiland Palisades Rd .. Patterson, NY
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
)WRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
EPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY
[]NEW SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 585 ft. I
STATIC WATER LEVEL 140 ft.
DATE MEASURED 10/10'/93
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING X0 OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 42 _ ft
MATERIALS: XV STEEL O PLASTIC ❑ OTHER
LENGTH BELOW GRADE LLI ft.
JOINTS: O WELDED XgRTHREADED O OTHER
DIAMETER 6 in.
SEAL.)aCEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 1_ Ib. /it.
DRIVE SHO ' YES O NO
I LINER: G YES O NO
SCREEN
DETAILS
- -- -- - - -
DIAMETER (in)
'SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
OYES ONO
OURS
SECOND ._
- .
... ..._
- - - -- - --
---- -.._ -• _
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER ii'DOEPTH
OF PACK
P
ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST ' If detailed pumping
I P P 9
METHOD: ❑ PUMPED tests were done is in-
COMPRESSED AIR , ! ormation attached?
❑ BAILED ❑ OTHER ❑ YES ❑ NO
1P1ELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SuafacE
water
Bear-
ing
WC11
Ora-
In
FORMATION DESCRIPTION
COCE
ft.
(t•
WELL DEPTH
it.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land
Surlace
Hard Dan
10
5
M iurl to nard grey & pinK grans
WATER ;.CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? y] YES ONO
ANALYSIS ATTACHED.' YES O NO
�� r
STORAGE TANK: TYPE'
CAPACITY :f G
PUMP INFORMATION
TYPE _ c-J CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
WELL DRILLER NAME I'IIH DRILLING, I ° TZ.1 /93
AOORESS Putnam ..Avenue SIGN
Brewster, NY Rpb 11 r Is e
J/89
NORYH AIJiIEMCAN
LABORATOM ESo NC.
ANALYSIS DATA SHEET
TYPE:
PW
LOCATION:
Weiland
REPORT TO:
Mill Drilling
ADDRESS:
Putnam Ave.
CITY, STATE, ZIP: Brewster, NY 10509
DATE COLLECTED:
11 -04 -93
TIME COLLECTED:
12:30 PM
COLLECTED BY:
RM
REPORT DATE:
11 -08 -93
LAB #
93 -5732
SAMPLE SOURCE:
DATE
ANALYSIS RESULT UNITS METHOD ANALYZED
Total Coliform MF Absent /100mL SM 17 (9215D)11 -04 -93
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
Labefatory Director
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11215
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754
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 PERMIT # 3
WELL LOCATION
Street Address
�®
To Village City Tax Grid Number
Ja
WELL OWNER
Name
11j trL
Mailing-
L
A ress
t0rivate
O Public
USE OF WELL
1 -41r imer
2- secon ary
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT S gpm /#
O REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING
PEOPLE SERVED /EST. OF DAILY USAGE gal
❑ TEST /OBSERVATION 12. ADDITIONAL SUPPLY
DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
G _
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name 1y1L.[_ jbg /LLIWr6 /NrG Address :,grwe9yy
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /,CITY
DISTANCE TO PROPERTY-_F.ROM NEAREST.-WATER MAIN:.. - - -= - -- _- __ - - -- ----- .- •-- __ -_ -- -. -
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SARATE SHEET ;.
( ate (aatey signature)
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
thirt3- (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 contaminate surface or groundwater.
Date of Issue: L'`�j� 19
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller