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Home My WebLink About1796DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -5 -6 BOX 16 01796 le- 116 11% 01796 WELL COMPLETION REPORT PUTNAM .COUNTY DEPARTMENT OF HEALTH 3/71 iJ `—Division of Environmental Health Services l COUNTY OFFICE BUILDING - CARMEL, NEW YORK sT This report is to be completed by well driller and submitted to County Health Department together With laboratory report of analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT ROUST BE SUBiVIITTEO WITHIN 30 DAYS OF WELL" CCIM' ETION OWNER NAME . ADDRESS » fi LOCATION OF WELL (No. &Street) (Town) (Lot Number). s tl PROPOSED USE OF " WELL BUSINESS DOMESTIC ❑ ESTABLISHMENT El FARM TEST WELL El SUPPLY ❑ INDUSTRIAL ❑; CONDITIONING ❑ ((SSpe ify) DRILLING EQUIPMENT COMPRESSED ; `CABLE OTHER .k ROTARY � AIR PERCUSSION ❑, PERCUSSION ❑ (Specify) CASING DETAILS LENGTH (lest) ��/ DIAMETER (inches) WEIGHT PER FOOT THREADED El WELDED SHOE YES ❑NO C-AWIG MYES ED7 NO YIELD TEST HOURS G.P.M. ❑ BAILED ❑ PUMPED AIR YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) J f/�% DURING YIELD TEST 1 feet) Depth of Completed Well in feet below Land surface: SCREEN MAKE _ LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (inches) IF GRAVEI`' . PACKED: ''`K Diameter of well including gravel pack (inches):. GRAVEL SIZE (Inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET (3.—u ta If yield was tested at different depths during drilling, list belw il\ FEET GALL e IWQ `* n 'i pull DATE WELL COMPLETED DATE OF REPORT t -• IWELLDRILL ER (Signature) W YORKTOWN MEDICAL LABUKAIUKY IN4. P.O. Box 99 321 Kear Street Yorktown Heights, N.Y. 10598 245 -3203 LOCATIONS: ❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245 -3203 ❑ 201 BUTTONWOOD AVE.. PEEKSKILL, N.Y. 10566 737.8777 ❑ 495 MAIN ST.; MT. KISCO. N.Y. 10549 666.3335 421"STONELEIGH AVE. (NEAR HOSPITAL), CARMEL. N. Y. 10512 278 -9330 LABORATORY REPORT mg /L LAB # DATE TAKEN: ❑ALUMINUM ................................ ............................... DATE RECEIVED: ❑ ANTIMONY ...............................:. ..............................• DATE REPORTED: ❑ ARSENIC ............................... ..... ............................... SAMPLE SOURCE: ❑ BARIUM ....................................... ............................... ❑ BROMIDE ................... ............................... ❑ BERYLLIUM ..:........ ............................... ................. REFERRED BY: ❑ BISMUTH ........................... .... ............................... COLLECTED BY: T\ e_" �P ❑ ACIDITY ................................................. ❑ALUMINUM ................................ ............................... ❑ ALKALINITY .................... .................... ❑ ANTIMONY ...............................:. ..............................• tjBACTERIA, TOTAL /mL ......... ....................... ❑ ARSENIC ............................... ..... ............................... ❑ BOD, 5 DAY ................... ............................... ❑ BARIUM ....................................... ............................... ❑ BROMIDE ................... ............................... ❑ BERYLLIUM ..:........ ............................... ................. ❑ CARBON DIOXIDE, FREE ......................... ❑ BISMUTH ........................... .... ............................... ❑ CHLORIDE ................... ............................... ❑ BORON ........................................ ............................... ❑ CHLORINE ................... ............................... ❑ CADMIUM ............................... ............................... . ❑ COO ........................... ............................... ❑ CALCIUM ................. ............................... ............... ❑ COLOR ....................... ............................... ❑ CHROMIUM (tot.) ............................ ............................... ❑ CYANIDE ................... ............................... ❑ CHROMIUM (hexavalent) .................... ............................... ❑ DETERGENT, ANIONIC ... ............................... ❑ COBALT .....................:.............. ............................... ❑ FLUORIDE ................... ............................... ❑ COPPER .................................... ....:................. :........ ❑ HARDNESS ................................. :................ ❑ COLD ................................................. :..................... _❑ COLIFORM COUNT/ 100 ml ..................... ❑ IRON ........................................ ............................... :9I 14 T COLIFORM COUNT/ 100 ml ........, ❑ CONFIRMATORY TEST .................................. ❑ LITHIUM ❑ NITROGEN, AMMONIA ... ............................... ❑ MAGNESIUM ................................ ............................... �❑ NITROGEN* ..: :....:......................... 1:1 MANGANESE :....:.........:: ❑ NITROGEN. NITRATE ... ............................... ❑ MERCURY .................................... ............................... ❑ NITROGEN, ORGANIC ... ............................... ❑ NICKEL................ ........................ ............................... ❑ ODOR ...................................................... ❑ PALLADIUM ................................ ............................... '❑ OIL & GREASE ............... ............................... ❑ POTASSIUM ................................ ............................... ❑ pH .......................................................... ❑ RHODIUM ................... ............................... ............. ❑ PHENOL ....................................................... ❑ SELENIUM .............................. ............................... ❑ PHOSPHATE (ortho) ....... ............................... ❑ SILICON ................ ............................... .. ..... ❑ PHOSPHATE (condensed) ... ............................... ❑ SILVER .............. ... ❑ PHOSPHATE (total) ..... . ....... .................... .. ❑ SODIUM ............................ R.E. .................. ❑ SOLIDS, SETTLEABLE, ml /L .......................... ❑ TIN ............................................ ............................... ❑ SOLIDS, SUSPENDED ... ...................:........... ❑ ZINC ....................... ..................�,...t..;..i( %�............. ❑ SOLIDS, DISSOLVED .................... .............. ❑ .................................................... ............................... ❑ SOLIDS. TOTAL .....: ..... ............................... ❑ ........... ...... ....... ❑ SOLIDS, VOLATILE ❑ REMARKS: ............. .•. ❑ SPECIFIC CONDUCTANCE 11 ...... .................................. ❑ SULFATE ................... ............................... ❑ .............:.....:................................ ............................... ❑ SULFIDE .................... ............................... ❑ .................................................... ............................... ❑ SULFITE .................................................... ❑ .................................................... ............................... ❑ SURFACTANTS ............ ............................... ❑ .................................................... ............................... ❑ TURBIDITY ....................... .................... ❑ .............. ........................................... _.. _._...- ....... THESE RESULTS INDICATE THAT THE WATER WAS F A SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED. THESE RESULTS INDICATE THAT THE WATER DID MEET THE SATISFACTORY CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE RULES .& _ REGULA IONS, DRINKING ATER STANDARDS (PART 72) FOR THE PARAMETERS TESTED. a ALBERT H. PADOVANI M.T (ASCP), DIRECTOR: f 4QA Municipality —Z?-e el /f,56&j A—� Building Type Subdivision Name Subdv. Lot ,'# GUARANTEE.OF SEPARATE SEWAGE SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving.the above described property, and that it has beer. constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his success- ors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of initial use of the sewage disposal system, or any, repairs made by me to such system, except where the failure' ",,;;. to operate properly is caused by the willful or negligent act of the occu- pant of the building utilizing. the system. - - The- undersigned further agrees to accept as conclusive the determin- ation of the Director of the Division of Environmental Health'Services of the Putnam County Department of Health as to whether or not the fail- ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this__,.? day of Title t1 ROGER. AYES CO ST. INC. BRUTHERS D PO.UGH UA Corporation Name if core.) Address w THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFOpzP CERTIFICATE OF COMPLETION WILL BE ISSUED. -n 1`._198 GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF M. DEV. OF HEALT'A l Division of Environmental Health Services, Putnam County Department of Health n � C Owner or Purchaser 6f7Building Secti.on_.. Building Constructed by Block+ Locat,fon Lot treet f 4QA Municipality —Z?-e el /f,56&j A—� Building Type Subdivision Name Subdv. Lot ,'# GUARANTEE.OF SEPARATE SEWAGE SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving.the above described property, and that it has beer. constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his success- ors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of initial use of the sewage disposal system, or any, repairs made by me to such system, except where the failure' ",,;;. to operate properly is caused by the willful or negligent act of the occu- pant of the building utilizing. the system. - - The- undersigned further agrees to accept as conclusive the determin- ation of the Director of the Division of Environmental Health'Services of the Putnam County Department of Health as to whether or not the fail- ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this__,.? day of Title t1 ROGER. AYES CO ST. INC. BRUTHERS D PO.UGH UA Corporation Name if core.) Address w THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFOpzP CERTIFICATE OF COMPLETION WILL BE ISSUED. -n 1`._198 GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF M. DEV. OF HEALT'A l Division of Environmental Health Services, Putnam County Department of Health •4,