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BOX 11
01031
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
WELL LOCATION
Street Address
346...Haviland Drive
Town/Village/City
Tax Grid Number
WELL OWNER
Name.
Doninick• ica i
Mailing Address :
•346
xQPrivate
O Public
USE OF WELL
l - :primary
2- secondary
'. xQ RESIDENTIAL
O:BUSINESS.
Q INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP D ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL . O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /1i PEOPLE SERVED 2 /EST. OF DAILY USAGE__ al
E] REPLACE EXISTING SUPPLY O TEST /OBSERVATION Ll ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING EkDEEPEN EX ISTING WELL
REASON 'FOR
DRILLING
DETAILED
REASON FOR
•DRILLING
EXISTING WELL .VERY LOW "YTE Q
WELL TYPE
®DRILLED
.DRIVEN
[]DUG
[]GRAVEL
• 0OTHER
IS WELL SITE SUBJECT TO FLOODING.? YES xX .NO
IF WELL IS LOCATED `IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: pi_nam IakA
Lot No.
!WATER WELL CONTRACTOR: Name Mill Drilling, Inc.'' Address:75 Putnam Av.,Brewster, NT
d
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES XX NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
EBON SEPARATE SHEET-
. •
date 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.
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 man er as not to degrade or of a ise tam a �ur Lace or groundwater.
Date of Issue: Z 19�_
Date of Expiration Permit Issuing Official
Permit is Non- Transferr ble White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
gpr
A A • �ir� • —
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PUTNAM COUNTY_ DEPARTMEIItTT;OF.HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPO RT699 ".
Well Lbeati
34.6 Haviland
Drive
Town e:;, -'.. _..-
Patterson
Tax Grid -# - _._ -_. _ __ ..
Map Block Lot(s)
Well Owner:
Name: Address:
Dominick Licari, 346 Haviland Drive, Patterson, NY
Use of Well:
1- primary
2- secondary.
XXX Residential
Business
Industrial
Public Supply Air cond/heat pump Irrigation
Farm Test/monitoring Other(specify)
Institutional Standby
Drilling Equipment
Rotary
Cable percussion _X�L Compressed'air percussion Other (specify)
Well Type
Screened
Open end casing xx Open hole in bedrock Other
—
_.
Casing. Details
Total length 46 ft.
Length below grade 45 ft.
Diameter _in.
Weight per foot 17 lb /ft.
Materials: _= Steep . Plastic _ Other
Joints: Welded xx Threaded — Other
Seal: — Cement grout.. Bentonite _'Other
Drive shoe: xx. Yes _ No
Liner: Yes No
Screen. Details
Diameter (in),
Slot Size,
Length(ft).
Depth to Screen (ft)
Developed ?.
First
Yes,. No
Hour's
Second
Well Yield:Test
Bailed
Pumped X_ Compressed Air
Hours f)__
Yield _.g__ gpm
Depth`
,Data;
Measure from land surface - static (specify ft)
2Q
Durin field test(ft)
6 y
500
De Depth of completed well in feet
P
705...'
Well Log
If more detailed.
information.
descriptions or
sieve analyses
areravailable;; .. ..
please attach.
Depth From
Surface
Water
' :.Bearing;:.
Well
Diaineter(m)
Formation
_..,. :.. Description
ft;.._ ,
;:. .,ft..,;
Land,surface
12
Sandy soil ,.w /cobb1 es., _
12
33
Medium to hard granite w� /soft seam
`ck & hite an. re b194 -granite
_
t
. ti
:.
_......_. _ ._ .__............. _....._. _...._..._, ...__......_
If yield was.iested
at different depths
during drilling,.
list:
Feet
Gallons Per Minute
Pump /Storage• Tank1nformation
300
3/4
pump TypeSU mersi �kcity .
Depth ' 400.'. Model5GS07412
Voltage: 230 HP .3/4
Tank Type exi sti ngVolume 34 gel o
diaphra
400
1
500
2
'6.00,
2
705
5.
Date Well Completed _
1.2/1. /99
Putnam County Certification No.
2.
Date'of Report
1.2/1.4/99
We I ri r �igria t u
1VV rid: txacviocatton otmeltwitn dtstancesto at.least two permanent landmarks to begfoVtdeitlon'a gepanod gtfeettplan.
Well. Driller's Name. MILL DRILLING,, INC.' Address!: 75 Putnam AVeo, ' 6rewster,' NY
Signature: Date: 1:2/1.4/99
. 1
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WN