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BOX 11
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01164
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WELL UVMYLt'1:1U1v "rUml
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF'HEALTH
Office Use Only
STREET ADDRESS: 11INNIVILLAUXICHY TAX GRID NUMBER:
il-!o ilvosoll ,b e,
WELL LOCATION
WELL OWNER
NAME: ADDRESS: �� 77E7,
-40 D i E /TELaAe)M #6 tfUd.SvN .t�/z .. �/
gIVATE
0 PUBLIC
'USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY O AIRICONDAEAT PUMP ABANDONED
p BUSINESS O.FARM ',O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL '0 STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED.-- / EST. OF DAILY USAGES gal.
REASON FOR
DRILLING
O NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O' TEST /OBSERVATION
0 REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH OATH
ft. WELL DEPTH 4
STATIC WATER LEVEL � ft.
DATE MEASURED 'a
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION b DUG
O WELL POINT O, CABLE PERCUSSION 0. OTHER (spl:Cify):
WELL TYPE
1.0 SCREENED O OPEN END CASING. MOPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH �L1 fit-
MATERIALS: O'STEEL 0. PLASTIC O OTHER
CASING
DETAILS
LENGTH.BELOW:'GRADE 0 ft-
JOINTS: O WELDED OTHREADED ❑ OTHER
DIAMETER in.
SEAL: MEMENT GROUT b BENTONITE ❑ OTHER
WEIGHT, PER FOOT / Ib'. /ft.
DRIVE SHOE:J&YES' ONO
LINER :DYES is 4O
DIAMETER (in)
-SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft).
DEVELOPED?
SCREEN
DETAILS
FIRST
O YES ONO
SECOND .
_...:.
_,.
_ .
_ . _ .._
HOURS.,._�-
GRAVEL PACK
O YES
❑ NO
GRAVEL
SIZE:.
DIAMETER
OF PACK in..
TOP
DEPTH tt.
BOTTOM
DEPTH It,
WELL YIELD TEST " If detailed pumping
METH00: O PUMPED I tests were done is in-
X,COMPIESSEO AIR r formation attached?
❑ BAILt ❑ OTHER 0 YES 'ONO
WELL LOG i It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE `
Water
pear-
� "9
weR ,
Dia-
Inter
FORMATION DESCRIPTION
`
CODE.
ft.
ft.
WELL DM
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gFm.
Land
Surlace
W
WATER O CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS •
O COLORED ANALYZED? O YES ❑ NO
AALYSISATTACHED? OYES ONO
STORAGE TANK!: TYPE
CAPACITY GAL.
PUMP iiFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
WELL DRILLER NAME n - y sy� /� DATE
AODRESS2�� j 5rcrrkTU
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MEM
tell
Boyd Artesian Well, Co., Inc.
R-: D No. 5 -- _. Rte..:. -.52
Carmel, N.Y. 10512
(914) 225 -3196
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tell
Boyd Artesian Well, Co., Inc.
R-: D No. 5 -- _. Rte..:. -.52
Carmel, N.Y. 10512
(914) 225 -3196
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DEPARTMENT OF HEALTH .
i
Division of Environmental Health Services
e 1 TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONST R UCT A WATER - WELL
_ =pCHD _
PERMIT
WELL LOCATION
Street Address
own /Village City T
„`I tj� L,. f � P
e6
/�
WELL OWNER
Name {� _
1110
Address
Vl I &r4Wj +�
dLPrivate
❑ Public
USE OF WELL
1 - primary
2 - secondary
1pl RESIDENTIAL
❑ BUSINESS
❑ INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
❑ FARM ❑ TEST /OBSERVATION
b INSTITUTIONAL ❑ STAND -BY
❑ ABANDONED
❑ OTHER (specify
❑
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
❑ NEW SUPPLY []PROVIDE ADDITIONAL SUPPLY
W REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
,1` , ,e
WELL TYPE
® DRILLED
DRIVEN
®DUG
®
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( at--JEA (4,4 W.0 Co Address:�� s� (.U/LGl1 �liF
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERTY FROM NEAREST. WATER MAIN:
YES No
TOWN /VIL /CITY
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION [DON SEPARATE SHEE
Boyd Artesian Well Co., Ind.
(date) R. D. 5 -Route 52 signatu. e)
Carmel. . Y. ®51 '
0340 "Oy
TO CONSTRUCT A WATER WELL
This permit to construct one vrater 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.
Date of Issue: de O _19
Date of Expiration: __19 ermit Issu' ffic al
Permit is Non - Transferrable /Yi0 %r 14'-' S!I- _ "' S s/_'>�
8/86