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BOX 18
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DEPARTMENT OF HEALTH
UWW', WELL GUMYLETIULV ,KbrUmi
Division —Of ' Environmental H6alt PUTNAM COUNTY DEPARTMENT. OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TOWN/ I TAX GRID NUMBER:
79. Cameron Road Brewster, Nl�j..
WELL OWNER
NAME: ADDRESS:
Robert Villani 79 Cameron Rd., Brewster, Nth 160
PRIVATE
PUBLIC
USE OF WELL
1 - .primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STANQ -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO.,PEOPLE SERVED 3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
4DREPLACE EXISTING SUPPLY []TEST /OBSERVATION ❑ADDITIONAL SUPPLY.
[]NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
285.
WELL DEPTH ft.
10
STATIC WATER LEVEL ft.
10118196
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY 4�COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING xQcOPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 60 _ ft
MATERIALS: x kSTEEL . ❑ PLASTIC . ❑ OTHER
LENGTH BELOW GRADE 59 n-
JOINTS: O WELDED ,daTHREADED O OTHER
DIAMETER 6 in.
SEAL:>&EEMENT GROUT O BENTONITE 0OTHER
WEIGHT PER FOOT 19 lb./ft.
I DRIVE SHOE O YES D NO
I LINER: O YES O NO
SCREEN
_DETAILS.._
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it) _
DEVELOPED?
FIRST
OYES ONO
BOUR4
SECOND
... _ _......._. ,
._.._ . _ .... _ ..
... �_._
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH IL
BOTTOM
DEPTH ft.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED t tests were done is in-
xBCOMPRESSED AIR ; `. ormation attached?
O BAILED ❑ OTHER ; 0 YES 7 NO
If mare detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FaaM
SURFACE
g air
wen
Dia-
meter
FORMATION DESCRIPTION
cool
ft.
tt ling
WELL DEPTH
ft,
DURATION
hr. min.
ORAWOOWN
ft.
YIELD
gpm.
Land
50
Si 1t, sand & gravel .
5C
2&5
Medium to hard black & grey granit
.
285
6
-
200
45
4D T'Ti
rn:;
CO�'
WATER x�aCLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? >42LYES ONO
ANALYSIS ATTACHED?.13cYES ONO
"p
J «'
STORAGE TANK: TYPE biaphragm co rs—;
CAPACITY 62 GAI,. l
PUMP INFORMATION
TYPE ,submersible CAPACITY 7
MAKER . s DEPTH 100.
MODEL 7GS0541 l VOLTAGE 115 HP 112
WELLDAILLERNAME &1A /96
ADDRESS Putnam Ave. SI
Brewster, L' y 1
3/89
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
.. .:.. _ ... :.. _ .�.. ... _
APPLICATION TO CONSTRUCT A WATER WELL
PCHD
PERMIT #
WELL LOCATION
Street Address
79 Cameron Road,
Town/Village/City Tax Grid Number
Patterson,
WELL OWNER
Name Mailing Address
Robert Villani 79 Cameron Road,.
xWrivate
O Public
USE OF WELL
1 - primary
2- secondary
=Q RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT 5. gpm /# PEOPLE SERVED 2 /EST. OF DAILY USAGE_ al
REPLACE EXISTING SUPPLY 13 TEST/ OBSERVATION GI ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLINGI kDEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
L5 and rlvg n-11 yoru shallpw acrd low nie_ld.
WELL TYPE
149DRILLED
DRIVEN
ODUG
GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES roc NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name )Pl. a Address:PUTNM AW•, MMMp NJ
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES sac NO
NAME OF PUBLIC WATER SUPPLY: m/a TOWN /VIL /CITY
DISTANCE TO PROPERTY -FROM - NEAREST -WATER MAIN: Nor
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED / ,
O ON SEPARATE SHEET
10/15/96 ° Aff
(date) Bober Qke stiderit
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of 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 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 attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all.water or waste products from such well drilling operations be contained on' this
property and in such a manner as not to degrade or otherwise contaminate groundwater.
Date of Issue: 19 ',-
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
11 -05 -�n6 11:40PM FROM NORTHEAST LABS TO
i
ENVIR0NMENTAL -LAR0
A Division 4AT6,- theast Laboratories Inc.
M[n L PLAIN ROAD - ; �DA1+[SiTRY, CT 06811
Z,,..
BERLIN: I2� MML STREET - BERLN CT' 06037
�
T.A1i0RAT0Ri REPORT -- WA
MILL DRILL G,1NC.
Pi MARMA AV NUB
BREWSTE&' , ,Y, 10509
,i
ml = miliilitei
> ° Mimi
ND - none dE
1055519142795075 P.01
SUPPL
CT Ceit PH -0404
and PH -0606
N7l Cert: 11471
G
DATE SAMPLE COLLECTE7: ''10/30/96
TIME COLLECTED:
1:30 P.M.
COLLECTED BY:
R MILL SR-
DATE RECEIVED Q LAB:
10/30/96
DATE(S) TESTED:
10/3.,0/96
TESTED BY:
LAB #11471
REPORT DATE:
I1/4196
I
i •
VILLANI 79 CAMERON RD. , PATTERSON N.Y.
HOSE H.YBH
WELL
R D RESULT: RECQMMENDED.LPIT .
toliform (Baal a) 0 per 100 ml 0 per 100 ml
- Chlo>'ine Re ' ual ND nag/): - - - --
s W.Liter
d
itESULTS: LASED ON SAIi'I�'I-LES SUMMED: 10/30/96 �
i •
SAMPLE, - i TESTED ABC JJA: �X OTAELE or Fo POTABLE
(PEP STATE OF NEW YORK DEPT. OFe 1-MALTH SERVICES STANDARDS FOR POTABLE WATER)
1n
Laboratory Director
i•