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HomeMy WebLinkAbout1269DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.70 -1 -28 BOX 12 01269 'z {r 1!k `, 11 No. 1. �� 1 .r THIN �'1 '. jJ 1' !f I �T , -} I; No I 6. �' , 01269 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES t c^- r- "^tif"R' a t7 T"N K.� P tdnl,ki •;r "};7� f WeIl�Permit #x•ce:�t 'Y i,y;:.:f f,�i x n7li'Lx`'�r"Y ��I'�. I WELL COMPLETION REPORT Well Location Street Address: 19 Salisbury Rd Town/Village: patte on Tax Map # 25.70 -1 -28 Map Block Lot(s) GPS-; `;', ;, t "? Well Owner: Name: 1 Address: Scott Edwards 19 Salisbury Rd.Patterson, NY 12563 Use of Well: 1- Primary 2- Secondary X Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test /monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion }_Compressed air percussion Other(specify) Well Type Screened _Open end casing X Open hole in bedrock Other Casing Details Total Length eft. Lengthl below grade _ft. Diameter 6 in. Weightlper foot 17 lb /ft Materials: X Steel Plastic Other r. Joints: Welded X Threaded Other Seal: X Cement grout Bentonite Other Drive shoe: Yes _ No Liner: _Yes No Screen Details Diameter (in) Slot Size Length ft Dept to Screen ft Developed? First _Yes No Hours Second Well Yield Test _Bailed _Pumped � Compressed Air' Hours _� Yield gpm Depth Date Measure from an su ace - static (specify ft , 20 During yield test (ft) 410 Dept o compjeted well in ft. 410 Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. I ft. Land surface 4 Q., Soi I hcil di;�rsci- 40 _ 140 Shale 40 250 Red Rock 250 410 Mica Ouartz If yield was tested at different depths during drilling list: Feet; Gallons Per Minute Pump /Storage Tank Information Pump Typ%il erged Capacity Sg m Depth 4 0 0--f eet ModelS(;s O 7 41 2 Voltage 230 HP 314 Tank TypeWX202 Volume Date well completed 4'/ 2 3 / 2 01 +1; :Well Duller PC Certificate # NY;State # N 01 4 ,sYRD1, 0 PumpInstaller R0,0 ertificate # NY State Date of Report` ,� WelI,DrillerName 8 Address ; ' 'Well .. ury;;GT Wra Wel.l:,,Drti 111. Driller�(st tur V"Orsl� g ` Pump 1nstaI WIN ame &, Adtlress w t s rt 1 g x_ M i 1;-z .w•. "; + s. ,de .,1i 7 K It. ,! .�, d. �r. .,x. �...G ,'x .,s. Pump Installer (signature) t vFa i fzt # N rlr�iiL�gry NU I t: txact Location of well wan distances to at ieast two permanent �anamarKS to oe provioea on a separate sneet/pian. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 �1)1`e:w,110 ��� t.g�.i�.�,y °+� . "� •�t.ire ��i ie `,���� APPLKATION TO ABANDON A WATER WELL please print or, type PCHD PERMIT # WeIIl Location: Street ' Address: TownNillage Tax Grid k 0 oSa'(1AVrij Ad PA & Bloc Lt �# s )� S'00 ap�8 Well Owner: Name: Address: 11WAR Type: Drilled Driven Dug Gravel Other Depth Matz: Well Depth ft Static Water Level ft Date Measured Use of Well: / Residential Public. Supply Air /Cond/Heat Pump Abandoned A- pnimma yq Business Farm Test/Observation Other (specify) 2- secondair°y Industrial Institutional Standby Water Well Contractor: Name: Address: ®d Wr&qq Wtv v i - 172- 8 &6- - Rox�U . c Reason II+'or AAbandonment: ° � e i.S �,6 / b/ l � ✓� Description of Work To Be Performed: ��� a � t�2 13 10D p Qw1 to G41P /; �� �pdii OAII Lo 4 sa Date: i " Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. 4 —��% Date of Issue White copy: HID file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL pleise`print or type PCHD Permit #W7 Well Location: Street Address: Town/Village Tax Grid # a S• 70 Ir Map 0,3 Block Lot(s) Well Owner: Name: Address: J LL r�. Te rSc► Use of Well: _V*- Residential Public Supply Air/ ond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage gal. Reason for ✓ Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realt y subdivision? ...................................... ........... ..................:.. Yes No Name of subdivision Lot No. Water Well Contractor:;'. (� Address: I ' Is Public Water Supply availab o site? ................................ ............................... Yes No Name of Public Water Supply: °-- Town/Village —" Distance to property from nearest water main: -- Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: Pwq�04-v PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. / If Date of Issue 4-2 , / / Permit Issu' Official: j Date of Expiration A— Title: Permit is Non - Transferrable A ` White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; t6range copy - Well driller © cas' i fv�-- W ° 1 IST, F eq) v a -Ye of Form WP -97 T3 SHERLITA AIiILER, MD, MS, FAAP Commissioner of Health ROBERT MORRIS, PE Director of Environmental Health Wragg Well drilling 172 Baker Rd Roxbury, CT 06783 DEPARTMENT OF HEALTH 1Geneva Road, Brewster, New York 10509 Subject: Proposed Well Edwards 19 Salisbury Rd. (T) Patterson April 29, 2011 Dear Wragg Well Drilling: PAUL >ELDRII)GE Countv Executive A field inspection was conducted on the above referenced lot by Vincent Perrin, Public Health Technician. The application to drill a new well is approved with the following stipulations- 1. The well pump and any electrical components are to-be removed from the existing well during abandonment. 2. The well is to be constructed with a minimum of 69 feet of casing. 3. A Well Completion Report (WC -97) shall be submitted no later than 30 days after the well completion by the permittee. Please contact me at (845) 808 -1390 ext.43131 if you have any questions. Sincerely, Vincent Perrin Public Health Technician cc: file Office (845) 808 -1390 Fax (845) 278 -7921 Q \ \ i84 : \ o0 moo \ \ V \ O �t . J � o co co- - - - -- A -951 ` A -931 A -950_ - `, ,A -930 , \ A -949 ' ' A -929 . A -948 A -928 ` ` A -947 ' ` \ � \ \ \ col* ` - i cP J J Sucu v� ve� Wea. 0 wk �¢ U ov