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01091
Aa' Wt;LL L;urirLt.:iiuiv mxvai
* * DEPARTMENT OF HEALTH
- Division Of Environmental Health Services
�� Y�� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TOWN191ELACKICIly TAX GRIO'NUMBER:
8 OaVield i>rive Patterson, IVIJ,
WELL OWNER
NAME: ADDRESS:
Alan Epstein 3 Thorrrwood Rd.; Armonk, NY
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
xfn RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
0 BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
j3REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
nNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
! 385
WELL DEPTH ft.
153
STATIC WATER LEVEL ft.
9116193
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 75 — ft.
MATERIALS: ,WTEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 74 ft.
JOINTS: O WELDED =9 THREADED ❑OTHER
DIAMETER 6 in.
SEAL: CEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT 19 Ib. /ft.
I DRIVE SHOE::aYES O NO
I LINER: fJ YES O NO
SCREEN
DETAILS
_........�
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND .. .
_
_.. :...:
_
_.. '_ ._ ._ .
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH It.
BOTTOM
DEPTH ft.
WELL YIELD TEST It detailed pumping
P P 9
METH00: ❑ PUMPED tests were done is in-
COMPRESSED AIR , ! ormation attached?
❑ BAILED ❑ OTHER : ❑ YES 0 NO
It more detailed formation descriptions or sieve analyses
1�IELL LOG are available, please attach.
DEPTH FROM
SURFACE
r e
B watear-
in9
W
We11
meter
FORMATION DESCRIPTION
poi
ft.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
10
Hardpan
10.
385
a grey grant e
385
6
-
TY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? xW YES ❑ NO
ANALYSIS ATTACHEDW YES O NO
[MAKER R CLEAR TEMP.
STORAGE TANK: TYPE $u OTMS.
CAPACITY GAir.
P INFORMATION
L
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME Mill. 1�Z111 °' . QQl+' 93
ADDRESS Putnam Avenue SIGN RE Ilk
Brewster, IV(J Ro a t1 t e
J /bv
ANALYSIS DATA SHEET
TYPE: PW
LOCATION: Epstein
REPORT TO: Mill Drilling
ADDRESS: Putnam Avenue
CITY, STATE, ZIP: Brewster, NY 10509
DATE COLLECTED: 09 -17 -93
TIME COLLECTED:
COLLECTED BY:
REPORT DATE:
LAB #
...—..—SAMPLE SOURCE:
3:30 PM
Mill Drilling
09 -21 -93
93 -4667
DATE
ANALYSIS RESULT UNITS METHOD ANALYZED
Total Coliform MF Absent SM17 (9215D) 09 -17 -93
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
tory Director
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address Town/Village/City Tax
8 Oakfield Drive PutnaM Lake , Patterso
Grid Number
i WELL OWNER
Name Mailing Address
Alan Epstein, 3 Thornwood Rd., Armonk, 10504
Wrivate
13 Public
USE . OF. WELL
1 - primary
'2 - secondary
RESIDENTIAL []PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
11 INDUSTRIAL CIINSTITUTIONAL O STAND -BY
O ABANDONED
13 OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE °'S.E-RVEDr`' .._'. /EST. OF DAILY USAGE gal
j.
;REASON FOR
DRILLING
ONEW SUPPLY ❑PROVIDE 'ADDITIONAL SUPPLY
PLACE. EXISTING SUPPLY EEPEN EXISTING WELL
❑TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
112 Ft. 6" '
WELL TYPE" "'DRILLED
13DRIVEN
DUG
GRAVEL
C1 OTHER
IS WELL-SITE SUBJECT TO FLOODING? `. YES
xx
_N0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY•AVAILABLE TO-SITE:- YES __X)L_N0
NAME OF PUBLIC WATER SUPPLY: "� " TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST MATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVID
aON REAR OF THIS APPLICATION RX t S
(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
2. Disinfect the well in accordance
County Health Department attached
3. Submit a Well Completion Report o
Health Department.
Date of Issue: if) aezl v 19
Date of Expiration. 19�
Permit is Non - Transferrable
2/87
clear.
with the requirements of the Putnam
to this permit.
n a form provided by the Putnam County
Permit issuing Offfcia
White copy: H. D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
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