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01141
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL S
PCHD PERMIT #
WELL LOCATION
Street Address
2
�r Town Vil ge City Tax Grid Number
r, 10_ _ 9
s
WELL OWNER
Name r
iq fffL
Mailing Addres
lb# G $ C
rivate
O Public
US WELL
- rimary
2- secondary
jgRESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP j'ABANDONED& SX
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED_j /EST. OF DAILY USAGE /V 8a1
REPLACE EXISTING SUPPLY O'TEST /OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING 13 !DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
, I9J W
— C
AI
WELL TYPE
10DRILLED
DRIVEN
DDUG
CIGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES yL NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
. Ii..
WATER WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY. FROM. NEAREST.WATER..MAIN:_. Alil-
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDSD�
ON SEPARATE SHEET
Z %S
(date) ( ignature
I
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
any and all water or waste products from such well
property and in such a manner as not to degrade or
Date of Issue: 2- 19
Date of Expiration 14.)
Permit is Non - Transferrable
3/89
shall take appropriate action to assure that
drilling operations be contained on this
otherwise con ' a e sur'€ac 1 g ,pundwater.
Permit Issuing Official
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
i
4
TARLTON ENVIRONMENTAL LABORATORIES, INC.
A Division of Northeast Laboratories, Inc. CT Celt: PH -0404
DANBURY: 22 KENosIA AVENUE - DANBURY, CT 06810 and PH-0606
__BERLIN: .. 129 MILL STREET - BERLIN;-CT-06037 - ...NY Cert:. 11471 ._. _.
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING
PUTNAM AVENUE
BREWSTER, N.Y. 10509
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
DATE(S) TESTED:
TESTED BY:'
REPORT DATE:
10/30/95
NOT STATED
ROB MILL 1R.
10/30/95
10/30/95
LAB #11741
11/1/95
SAMPLE SITE: LaBANCA, 92 LAKE SHORE DR., PUTNAM LAKE, N.Y.
f SAMPLING POINT: PUMP DISCHARGE
SOURCE: WELL- DRILLED -OLD
TREATMENT: NONE
TEST PERFORMED RESULT:. RECOMMENDED LIMIT
BACTERIAL:
Total Coliform (Bacteria) PRESENT per 100 ml ABSENT
E Coli (Bacteria) POSITIVE NEGATIVE
CHEMISTRY:
Chlorine Residual ND mg/L - - - --
H = milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMITTED :10 130/95
SAMPLE, AS TESTED ABOVE: y IMPOTABLE or MNOT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
.0 P1z
CT: DANBURYAREA (203) 748 -7903 - FAX (203) 748 -0652 - CT: NEIVBRITAIN/HARTF,ORDAREA (203) 828 -9787 -FAX (203) 829 -1050
TOLL FREE WITHIN CT: 800 -826 -0105 - OUTSIDE CT: 800 - 654 -1230
i i T-
5903 I 5904 I 5905
N 01'16 "40 " W 40.00"
PIPE FOUND
0/5 0.1' SE -sTJr /f N'AL:
I 2
N
578.3
FRAME p
SHED I O O
Rj ' NA
Jr/F k 50NRY
f RETAINING WALL
N 01'16 "40 " W 20.00"
Z
Co
N
— ^ 5 5790 5789 p w
577 5784
9 1�1 I I O N - :o.�:. N:T. WALL
a1 O E FACE .ie4R P
n1 PIPE FOUND \ PNC FOUND
ON UNE S O5'
'•\ w 1.0'
N 01'16'40"" W
LONG. CJ ?R"
20.00"
'" l i —'•6' 1, 5' COR."7NCE• /
FOUNO 0.2' S
I ca
I �
W? I z o
', rfl
u-
p Do I I STORY
cn I FRAME �•
DWELLING Sll,'n'AJL Fe'CE•••
I
1 F.
I
1,� I
- ...nER •. '� i
. RI7UNIl.•7J:
rAVEUENT
LJ 1995 INSITE ENGINEERING & SURVEYING, P.C.
Permit. #W - 104 -95 Lam/ /0
� v ' WELL UUMYL61 iUN KPIXUxr
* * DEPARTMENT OF HEALTH
Division Of Environmental Health'Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Of f ide Use Only
WELL LOCATION
STREET AOURESS: TOWNIVIELACLICIlY TAX GRID NUMBER:
92 Lakeshore Drive P tterson NY 25.56 -1 -49
WELL OWNER
NAME. ADDRESS:
Frank LaBanca Patterson New York
VBIVATE
❑ PUBLIC
USE'OF WELL
1 - primary
2 - secondary
1YRESIDENTIAL O PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
J31REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
[]NEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 2 8 5 ft.
STATIC WATER LEVEL 15 ft.
DATE MEASURED 11/7/95
DRILLING
EQUIPMENT
❑ ROTARY 9UMPRESSED AIR PERCUSSION O DUG
O WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING xEkOPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 75 - ft
MATERIALS: AUTEEL O PLASTIC O OTHER
LENGTH BELOW GRADE ft.
JOINTS: O WELDED a3THREADED O OTHER
DIAMETER 6 in.
SEAIx,,UCEMENT GROUT ❑ BENTONITE OOTHER
WEIGHT PER FOOT 19 Ib. /ft.
DRIVE SHOE: ❑ YES ❑ NO LINER: DYES ONO
SCREEN
DETAILS
-- - ....
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
OYES ONO
HOURS
SECOND.
_
-- - ... _ . _
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK In I
TOP
DEPTH ft.
BOTTOM
DEPTH K.
WELL YIELD TEST It detailed pumping
METHOO: ❑ PUMPED 1 tests were done is in-
&CEMPRESSED AIR , ` ormation attached?
O BAILED O OTHER i ❑ YES 0 NO
r9 ri i LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
in4
well
Dia-
meter
FORMATION DESCRIPTION
coot
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Land
15
Hard-packed clay & boulders
Medium to hard re bedrock
285
6
-
200
5
w /soft seams
44
285
Hard re granite w/ uartzit
s
WATER )U CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? MYES ONO
ANALYSIS ATTACHED ?A1YES O NO
STORAGE TANK: TYPE diaphragm
CAPACITY 44 G �, 12
PUMP INFORMATION
TYPE sub me r s ib 1 e CAPACITY 5
MAKER Goulds DEPTH 200
MODEL 5ES05 VOLTAGE 23%P1 2
WELL DRILLER NAME OAT
AooRESS MILL DRILLING, IN ,Jy C,.{ r I s
N
Putnam Ave., Brewster,NY R �'�
0
amsi
.
Putnam County Department of Health
Environmental Health Services.
Two County Building
Carrel, New York 10512
I, the undersigned, hereby certify •that the abandon-
ment of my water well has been accomplished in accord-
. i _.
ante with the methods described in my application for
a permit to abandon said water well.
(Date) (Si nature)
. -
(Print Name)
l U fVe4
�4/ST�flr.
(Address)
K E TARLTON ENVIRONMENTAL LABORATORY, INC.
A Division of Northeast Laboratories, Inc. CT Cert: PH -0404
- ...DAN13URY: ,39 -MILL PLAIN ROAD - UNIT #3 - DANBURY, .CT. 068.11. _ ._and 'NY Cert: 11741
L LA B S BERLIN: 129 MILL STREET - BERLIN, CT 06037 - CT Cert: PH0606
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING
PUTNAM AVENUE
BREWSTER, N.Y. 10509
SAMPLE SITE:
SAMPLING POINT:
SOURCE:
TREATMENT:
I... _:. - . TEST.PERFORAMD_:_ _ .. _
BACTERIAL:
Total Coliform (Bacteria)
CHEMISTRY:
Chlorine Residual
m1= milliliter
mg/L = milligrams per Liter
ND = none detected
DATE SAMPLE COLLECTED: 11/20/95
TIME COLLECTED:
2:15 P.M.
COLLECTED BY:
ROBERT JR.
DATE RECEIVED @ LAB:
11/20/95.
DATE(S) TESTED: -
11/20/95
TESTED BY:
LAB #11741
REPORT DATE:
11/22/95
LaBANCA, 92 LAKE SHORE DR., PATTERSON,.N.Y.
'HOSE BIB
WELL- DRILLED -NEW
NONE
RESULT: ... RECOMMENDED.LI IIT
0 per 100 ml 0 per 100 ml
ND mg/L - - - --
RESULTS BASED ON SAMPLES SUBMITTED:11h0 /95
SAMPLE, AS TESTED ABOVE: OTABLE or aOT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
CT: DANDURYAREA (203) 748 -7903 - FAX (203) 748 -0652 - CT: NEWBRITAINf L4kTF'ORDARF/1(`20J) 828 =9787 - FAX (203)!$29 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 - OUTSIDE CT: 800 -654 -1230