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HomeMy WebLinkAbout1354DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -62 BOX 13 01354 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # A yl%0 7-00 • Well Location: Address: TownNillage Tax Grid # 74 Empire Drive Patterson, NY Map Block Lot(s) Well Owner: Name: Address: John Petrillo 74 Fmpire Drive - Patterson NY 12563 Well Type: X Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured 4 2 Use of Well: X Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Mi.1 k 11in$, Inc. 75 Putnam Avenue Brewster, NY 10509 Reason For Abandonment: lack of water Description of Work To Be Performed: .j Fill with bentonite plug fran bottan to top Date: 4/4/08 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. Date of Issue Permit Issui f C--./ O ci Y tle White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - W driller Form WA -97 ss Ts� 106 ` llo� ,t 02 I/ PUTNAM COUNTY'DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location ° Street Address: 74 Empire Drive Town/Village: Patterson Tax Map # 25.78r1�? Map ock Lots) GPS l 41 °27'S4W 073 °33'05W Well Owner: Name: Address: John Petrillo 74 Empire Drive Patterson, NY 12563 Use of Well: X _Residential _Public Supply Air cond /heat pump _Irrigation 1- Primary XX Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion X Compressed air percussion Other(specify) Well Type Screened _Open end casing __L Open hole in bedrock Other, Total Length __4Lft. Materials: I Steel Plastic Other Joints: Welded Threaded Other Casing Details Length below grade Mft. Seal: Cement grout X Bentonite Other Diameter 6 in. Drive shoe: X Yes _ No Liner: _Yes _L__No Weight per foot JZ_Ib /ft Diameter (in) Slot Size Length ft Dept to Screen ft Develo ped? Screen Details First I _Yes No Second I I Hours Well Yield Test _Bailed Pumped _ Compressed Air Hours Yield gpm Depth Date Measure from land su ace - static (specify rtj During yield test (ft) Depth of competed well in ft. W 140 440 Well Log Depth From Surface Well Diameter ft. ft. If more detailed Water Bearing in Formation Description information LandSUrface,. descriptions or lg sieve analyses are available, please attach. If yield was tested Feet a Ion JW191inute Pump /Storage Tank Information Pump Type Capacity at different depths during drilling Depth Model list: Voltage HP Tank Type Volume Date Well Completed ,Well€ r 4/2508 s, ,Pump Driller PC' Certificate =# ` NYState #` X10071` Installer PC�Certlficate #`'� x sNY e# f Date of Report "` " 0. /OS .... MUD till �A 5' i a � Y� lit ll Dxallurg, Ine 75'Putr�arn Ave Brewster, NY 10509 " �`k .., ,. ..*. :>..,,.... .A n.�,. .. ��. .a%', x. ., sr, z.�d,..ixu �,. .xa:. ,. E,,.na>�:. ..¢,. .i.L :iM ➢�,:€s .""S..�C� 3Srax �� Well Dr r tgnature)¢ e. Pumdp£Installer Name& Address wX ,y . ..x �'`.� 7 T'J d:..[YL ..: rw. :i. yR 'x ". l : v '" wL.r..#d'��'niA�..« -}viv y'y3i � ...w..cA,,:�a- A hx`e'...'Y'...i3:', i'.u.:es';.,'a« r 7 "'s'�T✓i�i.z.'°✓+P.Li�a+*Y.er ump(Installer(slgnattare) , e$sc+x: ,v'^., s.IK�x w..a'a '�.' Yf, v��'. kR✓, IIma4'.°'L" ?_ NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 e Page 1 of 1 EetrfroaatrrstataF5e fca3, 1,7 41 KarrooaiaAvsrwe 1 ifIATER, SOIL AND AIR ANALYSIS Danbury, Connocucift 48WO I Tebephons 203 -708 -2229 Mill Drilling Co Mailing Information: ' Collector's Information: JMS ID: 070508 Name: Mill Drilling Co Name: Russ Mill Address: 75 Putnam Avenue Address of site: John Petrillo 74 Empire Drive City: Brewster City: Brewster 3 State: NY Zip: 10509 State: NY Zip: 10509 F Phone: (845) 279 -5041 Fax: (845) 279 -5075 Phone: Sample's Information: Site: Hose Bib Date Collected: Preservative: HNO' Time Collected: Temperature: <4 Matrix: Water 5/28/2008 12:30:00 PM Date Received: 5/28/2008 Time Received: 2:10:00 PM Lab No.: J0805638 Date Analyzed Test Name Result MCL Method 06/02/08 Manganese <0.05 ppm 0.3 ppm SM 3111 B 06/02/08 Sodium 14.7 ppm N/A SM 3111 B 05/28/08 pH 6.95 S.U. 6.5 -8.5 S.U. SM 4500 H B 05/28/08 Color ND 15 Units SMWW 2120 B 05/28108 Turbidity 0.34.ntu 5 ntu SMWW 2130 B 06/02/08 Hardness 152 mg /L N/A SMWW 2340 C 05/28/08 Odor ND N/A SMWW 2340 C 06/02/08 Iron <0.05 ppm 0.3 ppm SMWW 3111 B 06/02/08 Chloride 103 ppm 250 ppm SMWW 4110 B 06/02/08 Nitrate 2.02 ppm 10 ppm SMWW 4110 B 06/02/08 Nitrite 0.19 ppm 1 ppm S WNV4110 -B -- — 06/02/08 Sulfate 23 ppm 250 ppm SMWW 4110 B 05/28/08 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 05/28/08 E. Coli Absent Absent SMWW 9223 B 05/28/08 Total Coliform Absent Absent SMWW 9223 B Comments: At the time of the analysis the sample was Acceptable for Total Coliform At the time of the analysis the sample was Acceptable for E. Coli CFU = Coliform Forming Units MCL = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable ND = None Detected ntu = Nephelopmetric Turbidity Unit ppm = parts per million S.U. = Standard Unit Units = Units Signature: Reviewed BY Michael Lapman Sharon Houlahan, Director President State #: PH -0218 ELAP #: 11715 CONNECTICUT, NEW YURK AN NELAC OrRTIRE0 Toll Free Bee- JMS -Bow I Corporate Fax 203 -79B -2408 1 Lab Fax 203 -798 -2107 I wwwjm9enAr©nrnental.com f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL ABANDONMENT REPORT Beason for 4m__ 6�] low yield - poor quality jo do remove ,jet puT lines, fin well with bentorate, 30 pellets WELL ABANDONMENT CERTIFICATION I, undersigned, hereby certify that the abandoment of the above-referenced water well has been accomplished and completed in accordance with the methods described in Permit # m7-o8 to abandon said water well. Date: 5/28/08 Signature: V_ Print Name: Russell C. M 1 ML11 Drilling, Inc. Address 75 Putnam Ave-, Brewster, NY 10509 Form WAR-97 zo arne: ress: John Petrillo 74 Empire Drive - Patterson, NY CT X Drilled d Driven ug Gravel Other Well Depth 116 ft Static Water Level 30 ft Date Measured 4/25/08 Beason for 4m__ 6�] low yield - poor quality jo do remove ,jet puT lines, fin well with bentorate, 30 pellets WELL ABANDONMENT CERTIFICATION I, undersigned, hereby certify that the abandoment of the above-referenced water well has been accomplished and completed in accordance with the methods described in Permit # m7-o8 to abandon said water well. Date: 5/28/08 Signature: V_ Print Name: Russell C. M 1 ML11 Drilling, Inc. Address 75 Putnam Ave-, Brewster, NY 10509 Form WAR-97 zo SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Rob Mill Mill Drilling, Inc. 75 Putnam Ave. Brewster, NY 10509 April 17, 2008 Dear Mr. Mill: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed Well Petrillo 74 Empire Dr. (T) Patterson A field inspection was conducted at the above referenced lot by Mitchell Lee, Public Health Technician. The application to drill a new well is approved with the following stipulations: 1. The well pump and all electrical components are to be removed from the existing well once it is abandoned. 2. 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) 225 -5186 ext. 2233 if you have any questions. Sincerely Mitchell D. Lee Public Health Technician c4e Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type Well Location Street Address: Town/Village: Tax Map # — 74 Empire Dive Patterson, NY . Map Block Lot(s) Well Owner: Name: dress: Phone #: John Petrillo E74 Empire Dive Patterson, NY 79 -7700 Use of Well: X Residential _Public Supply Air /cond /heat pump _Irrigation 1- Primary XXX Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served 2 Est. of Daily usage /a00 _gal. Replace Existing Supply TesUObservation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Low Yield - close to se tic ff stem for Drilling �___L_Drill Well Type e d Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ No X Is well located in a realty subdivision ? . ....................................... ............................... Yes _ No X Name of subdivision Lot No. , Address: 75 A,t „am Ayarn,a Water Well Contractor: X1;11 prj11 - -,IVY` �a Is Public Water Supply available on site ? ....... ..... ..... ............. ..... -,- Yes _ No Name of Public Water Supply: TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to be provid separate sheet/plan. -, April 3 2008 Date: Applicant Signature: `71 ao 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 Departmel 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 Commissioner of Health. Any revision or "the lan requires a new permit. Well to be constructed by a water well driller certified by Putna Date of Issue Permit Issui Official: Date of Expiration r Title: Permit is Non- Transferable White copy - HD file; Yellow copy'- Building Inspector; Pink copy - Oyler; Orange copy - Well driller Form WP -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL ABANDONMENT REPORT WELL ABANDONMENT CERTIFICATION I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and completed in accordance with the methods described in Permit # Ai W-08 to abandon said water well. Date: 9/30/08 Signature: Print Name: R • Mill Address: Mill Drilling, Inc 75 Putnam Ave., Brewster, NY 10509 Form WAR -97 PCHD Well Abandonment Permit # AW07- 8 please print or type Well Lpcat on Street Address: TownNillage Tax Grid # 25.78 -1-62 ' 7 74 Fmpire Drive Patterson Map Block Lot Name: Address: 4f John Petrillo 74 Empire Drive, Patterson, NY y F dell Ty�Ii - a�Y �_ Drilled Driven Dug Gravel Other a .T 3 Depth of+eh '� `'= Well Depth 116 ft Static Water Level 30 ft Date Measured 4/25/08 x, 8,, n `Q� I i d, ualit Y el poor quality �,baadonment nt±crrint�nri,nf ' +} Remove jet pump lines, fill well with bentonite - 3/8" pellets WELL ABANDONMENT CERTIFICATION I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and completed in accordance with the methods described in Permit # Ai W-08 to abandon said water well. Date: 9/30/08 Signature: Print Name: R • Mill Address: Mill Drilling, Inc 75 Putnam Ave., Brewster, NY 10509 Form WAR -97