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* * DEPARTMENT OF HEALTH
Division Of Environmental Health Services
YO __ ....... es
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
— Y'31
WELL LOCATION
STREET ADDRESS: TI WN I TAX GRID HUMOR'
33 Lakeport Drive, Patterson, New York
WELL OWNER
NAME., ADDRESS:
Michael See, 33 . Lakeport Dr„ Patterson, NY
XI PRIVATE
o PUBLIC
USE OF WELL
1- primary
2 - secondary
AMMESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify)
❑ IN,OUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3 -4 /EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
XDEPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY
[]NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 225 ft. I
STATIC WATER LEVEL 35 ft.
I DATE MEASURED 9/2/93
DRILLING
EQUIPMENT
❑ ROTARY XXKXCOMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING Xa OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH fit.
MATERIALS: X)QSTEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE ft.
JOINTS:,,_. ❑ WELDED XaTHREADED ❑ OTHER
DIAMETER 6 in.
SEALX.Q CEMENT GROUT O BENTONITE ❑OTHER
WEIGHT
PER FOOT 19 1b./ft.
I DRIVE SHO � p YES O NO LINER: 0YES O NO
SCREEN
. : DETAILS. ..
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
�.
o YES o No
... . .
HOURS
SEGUNO .....
GRAVEL PACK
❑YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH tL
BOTTOM
OEM IL
WELL YIELD TEST It detailed pumping
METHOD: ❑ PUMPED tests were done is in- I
COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ; ❑ YES O NO
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
VYi1tf
Bear -'
ing
Welt
Dia-
meter
FORMATION DESCRIPTION
c00e
ft.
IL
WELL DEPTH
It,
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land
Soft soil W /cobbles
granite
22
_
WATER )D(CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? X)pYES ONO
ANALYSIS ATTACHED YES ❑ NO
STORAGE TANK: TYPE lap ragm
CAPACITY 62 GAS.
PUMP INFORMATION
TYPE . submersible CAPACITY 10
M XI GOULDS D ��
MODEL Vl7tTAGE H�"
WELL DRILLER NAME ll
MILL DRI °I INC ,� /01 /93
ADDRESS Putnam Avenue sI � � � '� J '
Brewster, NY4� P1 "j,
ice'n
J/ bS f
i
' C•
�IIj'�(U�,Ojj'�j)L��"f�//��� AI�jj�E' �j�^O`,}`C�CAI�C
AZALYSIS DATA SHEET
TYPE: PW
LOCATIOZ -. See Residence
REPORT T®: Mill Drilling
ADDRESS: Putnam Avenue
CITY, STATE, ZIP; Brewster, NY. 10509
DATE COLLECTED: 09 -17 -93
TIME COLLECTED: 3:16 PM
COLLECTED BY: Mill Drilling
REPORT DATE: 09 -21 -93
LAB #.: 93 -4663
SAMPLE SOURCH: Oiutside hose bib
DATE
ARALYSIS RESULT UZITS METHOD AZALYZED
Total Coliform MF Absent SM 17 (9215D)09 -17 -93
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
rey Director
ZEN YORK STATE FLAP CERTIFICATIOZ Z ER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 1 0509 / 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 #
WELL LOCATION
Street Address Town Village City Y Tax Grid Number
33 Lakeport Drive Patterson, 1�I
WELL OWNER
Name
Michael See,
Mailing Address
33 Lakeport Drive, Patterson, NY
x®frivate
0Public
USE OF WELL
1 - primary
2- secondary
�GIESIDENTIAL
0 BUSINESS
13 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
M INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED 2 - EST. OF DAILY USAGX- �.�al
2a:tEPLACE EXISTING SUPPLY O 'TEST/ OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
Existing 6 drilled well has low yield.
WELL TYPE
x®DRILLED
DRIVEN ODUG GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES xxx NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Putnam Lake, Patterson, NY
Lot No.
WATER WELL CONTRACTOR: Name MILT, DRILLING, INC. Address: Putnam Ave.,. Brewster
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES xxx NO
NAME OF PUBLIC WATER SUPPLY: n/a TOWN /VIL /CITY
DISTANCE TO ",PRuPERT'�-- iF%02•`i- ►rEARE -ST -WATER --ME` IN:
no
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDEf''
OON SEPARATE SHEET. < a s t
8/31/93 'yi :;,
(date) (signature)
Robert M. Mill, President
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
thirt,, (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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink cop wner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUWY HEALTH DEPT
DIVISION OF EIMRC1%� IAL SIA,TH SERVICE
ON,, ",z-
i
dl
REGISTRATION #
Pro (include sketch locating all adjacent wells):
WME.- Repair must be in same location and of same type as original serge disposal syst m.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Inspector's S
tore &
Proposal Disapproved
u
tpposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showings
a. Omer ° s name.
b. Site Street Dame, Town and Tax leap number.
c. Location of installed components tied to two fixed paints (e.g.,hcuse corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diamo x 61 deep
drywells surrounded by one foot ¢ gravel).
e. Installer °s name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
as owner, or reported agent of owner agree to the above conditions.
SIGNATURE I Y TITLE
Cis Fit to (PC EW a YeUcw (fin HE); Pink (kliiault)
DATE
ti? i e- LJe °/ ,S ® e
t tI c- k o 1 f ja- n e,-+ S
33 Lakeport`'
T o
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