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BOX 18
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH' SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
&/
Town/Village -
.
V
Tax Grid #
Map Block
Well Owner:
Name: Address:
V64 y5Cfk'%b1't`4k0 L.'�( (C V
C'L v C, �11 r 10 kc� V� Ve
Use of Well:
1-primary
2-secondary
Residential Public Supply — Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional — Standby V)-e_e_VeLj
Drilling Equipment
Rotary _ Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length ft.
Length below grade ft.
Diameter in.
Weight per foot lb/ft.
Materials: — Steel — Plastic Other
Joints: Welded Threaded Other
Seal: — Cement grout Bentonite Other
Drive shoe: —Yes No
ILiner:— Yes —No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
— Yes—No
Hours
Second
Well Yield Test
Bailed --w— Pumped _�< Compressed Air
Hours
Yield -7 gpm
Depth Data
Measure from land surface-static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are-avai la le;- - - -- -
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)l
Formation
Description
ft.
ft.
Land Surface
//0
7cf
LIA, r k't k K Cl C L,
7"3
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump/Storage Tank Infifibati ---D
Plump Type I!!, Capa6i
Depth Model Zq 0
Voltage 0 HP
Tank Type L_ll -Vfu Volume
Date Well Completed
/� f �L - 7
Putnam County Certification No.
, i ()
Date of Repo eportr A 7
/L1
We I Driller (sign
I
NOTE: Exdct location of well with distances to at least two permanent landmarks to be provided on a separate bl � le le, Lv/ p 1,43 1.
16 L 050 ke " b-1
Well Drillees Nam Oc, k vecr Address: Kej ,_t
Signature: Date: 1 /7 L7
White copy: HD File; Yellow copy - Building Inspect ner; Orange copy - Well driller
7�7_n_ Form WC-97
�V. # (-e s'`1 P
iTTNAM COiTNTV DEPARTMENT OF HIP AT TII
® ° ® DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION - WELL - - -
ATION TO CONSTRUCT A WATER
please print or type PCHD hermit #�
Well Location:
Street Address: Town/Village Tax Grid #
q
43 6tIvi cal -- ewI4'er- Map 36.33Block Lot(s)
Well Owner:
Name:
a
Address:
Aam.
4#161
1�seWs'fef INN
Use of Well:
r)4r 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 302 gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
We �
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? .......... Yes No )c
Is well located in a realty subdivision? ...................................... ............................... Yes No >C
Name of subdivision Lot No.
Water Well Contractor: ' to � Address: It.7 & kow— &d— ge i'tw
Is Public Water Supply available o site? ................................ ............................... Yes No
Name of Public Water Supply: / f} Town/Village g re w-g & .-
Distance to property from nearest water main: ! IA-
Proposed well location & sources of contamination to be provided on separate sheet/plan.
_.
Date :.- - U 3 Applicant Signature:
PERMIT TO CONSTRUCT A WATER WELL
3
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code andpovided
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 m* 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/.gj=
well driller shall take appropriate action to assure that any and all water and waste products from swh 4 D-; =7
well drilling operations be contained on this property and in such a manner as not to degrade or od4jwis Z5
contaminate surface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires g yeartfrom 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.
1 I o
Date of Issue. 1 i 7 Permit Issuing Office
Date of Expiration y Title: 43s vs
Permit is Non-Trans f rra le
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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