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34. -5 -37.1
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01590
tom. 4
PUTNAM COUNTY DEPARTMENT OF HEALTH
r DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL -
v leas e ar'int or iyve PCHD Permit # L 1 kA - O a_
Well Location:
Street Address: Town/Villa Tax Grid # 34.-5-37.1
239 Farm to Market Rd, B er Q SQ Map Block Lot(s)
Well Owner:
Name:
Address:
1239
Frank Rotunda
Farm to Market Road, Brewster, NY 10509
Use of Well:
X Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 5 gpm # People Served Est. of Daily Usage gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) X Deepen Existing Well
Detailed Reason
Existing well is inadequate
for Drilling
Well Type
X Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor: P. F. Beal & Sons, Inc. Address: 4 Putnam Ave., Brewster, NY 1050
Is Public Water Supply available to 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: 7Z19/02 A plicant Si nature: _ -
istop Beal
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. revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water 11 ller certi fied by Putnam
County
Date of Issue Z Permit Issuing 0 1
Date of Expiration M30 b Title.
Permit is Non- Transferr ble
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
...........
H ALTH'b&r.-
PUTIAM COUNW. E
1•,GbniVa Road (1345) 27"130 024-102
Brewster, NY •10509
Date
..Received of
The Sum Of. Dollars $ 00
For
THANK YOU!
❑ Cash [theck, F1 M.0 ❑ Credit Card By
m
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT - REDRILL PCHD#W82-02
NOTE: Exact location of well with distances to at I least two permanent landmarks to b5Kovided on a separate sheet/plan.
Well Driller's Nam DRILLING, INC. Address: 75 Putnam Ave., Brewster, NY
Signature: Date:
White copy: HD File; Yellow copy -Building Inspector; Pinkcopy - Owner; Orange copy -Well driller
Form WC-97
239 Farm to .%rket Road
T-6
Patterson
Tiktfid'#"3*4'.-*-"*5 L`37:1--
Map Block Lot(s)
Well Owner:
Name: Address:
Frank Rotunda 239 Farn. to 14arket Patterson, Ny 12563
Use of Well:
1- primary XXXX
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 X Compressed air percussion _ Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length —ft.
Length below grade ft.
Diameter EXISTING 6 in.
Weight per foot 17 lb/ft.
Materials: X Steel — Plastic, Other
Joints: Welded Threaded _ Other S
FXT TTN,
Seal: Cement grout Bentonite Other
Drive shoe: — Yes No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
Bailed Pumped _L_ Compressed Air
Hours _6_
Yield _Sa_ gpm
Depth Data
Measure from land surface- static (specify ft)
15
During yield test(ft)
140
Depth of completed well in feet
205
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.
ft.
Land'Surface
1,EDRILL
-.70
Hard Gre_y &- Black Granite
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump/Storage Tank Information
205
50
Pump Type _ Capacity
Depth --MSTINQ Model
Voltage _ HIP
Tank Type Volume
Date Well Completed
3/18/03.
Putnam County Certification No.
2
Date of Report
3/21/03
Well Drill s' re)
NOTE: Exact location of well with distances to at I least two permanent landmarks to b5Kovided on a separate sheet/plan.
Well Driller's Nam DRILLING, INC. Address: 75 Putnam Ave., Brewster, NY
Signature: Date:
White copy: HD File; Yellow copy -Building Inspector; Pinkcopy - Owner; Orange copy -Well driller
Form WC-97
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