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HomeMy WebLinkAbout2233DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.05 -1-40 BOX 19 Arl i T E tIq%l WrL J lk IN , ti 0 Alm 02233 ,•�•; PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION-OF ENVIRONMENTAL HEALTH SERVICES 45 6 WELL COMPLETION REPORT Well Location Street Address: ����✓ Town /Village: y /t/�9�1�'.�L� Tax Map # Map / Block / Lot(s) GPS ``,3 Well Owner: Name: Address: Io Use of Well: 1- Primary 2- Secondary Residential _Public Supply, Air cond /heat pump _Irrigation Business . Farm Test/monitoring _Other(specify) Industrial Institutional Standby Drilling Equipment Rotary,`•Cable percussion >lCompressed air percussion Other(specify) Well Type Screened _Open end casing •,%6 Open hole in bedrock Other Casing Details Total Length Zft. Length below grade aft. Diameter _A�Lin. Weight'per foot / lb/ft Materials: Steel Plastic Other Joints: Welded -,'< Threaded Other Seal: X Cement grout Bentonite Other Drive shoe: ,�C Yes _ No Liner: _Yes �—No Screen Details Diameter in Slot Size Length ft Dept to Screen ft Develo ed? First _Yes _No Hours Second Well Yield Test _Bailed _Pumped Compressed Air Hours Yield gpm Depth Date Measure from an su ace -stat c spec 1 unni yield test r o compete we n . Well Log If more detailed If more .... infoFrnatioR descriptions or sieve analyses are available, please attach. Depth From Surface Water Well Diameter in Formation Description ft. ( ft. ! &2r 6 Ar 3 . -5 3 _' i✓F If yield was tested at different depths during drilling list: Feet PjAf Minute 11p14 Pump /Storage Tank Information V Pump Type Capacity Depth Model Voltage HP Tank Type Volume ® DateWell Completed tii Jr.. {7n r ...... .. ,.: z Welt`Driller;PCCertrficate�# . pp� # ',NY;State # °� /—:" ' , y t•� (.q�. rt t! Yry1�C'S pF�i L - •. n� X v i �y aXU , "r >T '' F': r S i .. y yT. 'fv x`4 s'7 ax: 1 t!` } .� ?:`•@. t ;�:'x s �' v Pump I.nstaller�PC Certificate. # State #� ..Y .. _._ ..... w-.:, .. ,. .:v F.,e'^t .. <. 4..... .....:x ... ✓�.., n. .. .. ... _..,. Dateof port' aj�; ";tint Well Dr,illerName'8r R Addre °ss "y.xa '_�` R Er z4t�gg t5. a ^f � ty�,'. ".y a�yE:: We I Dr ler (si na t. :w•;� ir+d`:» sa., awrP`Y`.,I 14 �y' °.l!''1 ,�x, � 'r, ,: s th X Ys hi:,� iii. ✓� t i1 .j d� Pum Installer Name 8�wrAtldress �. ,^"�, ma y: ` *�JS* , r wA� it (w` pG % k CP i. 11 J �' S°'(b'•� i �'�: .4+9' 4. '� Y ,�:; "v f .? <»...:. :.+ Z�r... 'Yd� ;.n' 4T ..': '�' F"aks a. xt'i :. § - .'... >. .:•ck'..: ., Zs.Y. a�. t«•k,. 5 ,tai. fv if k4ax::�s .1 ,i vF 'iL • ' g PuI A nM taller %(signature) a '.iy. d ,h �. r�w?"`td`a NOTE: Exact Location of we!p4vith dist nces to at least two permanent andm rks to be provided on a separate sheetiplan. Yt*4)0 ob/ JT:�J2l;Av K ¢ 1,i d / l 0410.4 White copy: HD File; Yellow copy - Building Inspector; Pink c� py - Vner; Orange copy - Well driller Form WC -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES u 03, 1, 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 #,,,:51 to abandon said water well. -Signature- Print Name: 4�11'w Address: Form WAR-97 PCHD Well Abandonment Permit #_Aw/;7—z9,7 please print or type "t Street Address: TownNillage Tax Grid # liu Map Block Lot Name: Address: Drilled Driven Dug Gravel _Other .0 _0 Well Depth ft Static Water Level ft Date Measured 0 �34 lly'd 'ify'd i4'dh hhu/ r_fiKe;4j1_ u 03, 1, 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 #,,,:51 to abandon said water well. -Signature- Print Name: 4�11'w Address: Form WAR-97 Obyd Artesian Vell Co., Inc 0 54 Rte..: .. ..... . ... - -, 52 Carmel, N.Y., 1051.2 (845) 225'3196.. Fax (845) 225 -8420' p .. vyfgt .1 ?04 A? N � MIZ C N li • POP p . . . . . . . . . . j5Y 1 ­1 , rr 4 / � Fln :I,a i mirtAnq I Azv89zZ9v8 19 :ET LOOZ/LO/IT SHERLDTA AMLER, MD, MS, IFAAP _ Commissioner_ of Health. LORE'I I'A MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Boyd Artesian Well Co., Inc. c/o Henry Boyd 1054 Route 52 Carmel, NY 10512 November 9, 2007 Dear Mr. Boyd: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed Well Manley 188 Lake Shore Dr (T) Putnam Valley A field inspection was conducted on the above referenced lot by Mitchell Lee, Public Health Technician. The application to drill a new well is approved with the following stipulation: 1. A Well Completion Report .(WC 797) shall be submitted no. later than 30 days after the well-completion by °the perrriittee. Please contact me at (845) 225 -5186 ext.2233 if you have any questions. cc:d1; Sincerely, �k�w � .. Mitchell D. Lee Public Health Technician 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 ABANDON A WATER WELL please print or type PCHD PERMIT # "tv1'-7 —C)� Well Location: Street Address: TownNillage Tax Grid # t tJ y egg L1q�ve. S.9np,¢e.1 Map Block Lot(s) Well Owner: Name: Address: Well Type: ✓Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft. Date Measured Use of Well: ✓ 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: W6 4 � 5 a C � � —3a9 le Contractor: of d bi- 'sir ��1 �o c� �o 1 toy LE) a a- Reason For Abandonment:.. Description of Work To Be Performed: Date: f lo 7 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 Pa,T submit to the Department a'certified statement that the information delineated on the application for this c permit has been completed. l O Date k I sue ermit Issuing Official A" Imo+ c Title 2. J- ... White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller NJ f Form WA -97 � I .4 . U© PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ lease print or a PCHDP WN Well Location Street Address": Town/Villa`g�e�:�,� Tax Map # �� OE LPrkc �� 41613lock rI"�"r(4h!',1Lfia Lot(s).116 Well Owner: Name: Address: Phone #: NCI � I I W L-Ak-e- Shue. "Zd. '7- �WV_ lVh D-9 -F& i Use of Well: Residential `Public Supply Air /cond /heat pump _Irrigation I - Primary Business Farm Test/monitoring - _Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought — Xa_gpm # People Served Est. of Daily usage a gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type 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. Well Contractor: cl Address: I.({ 57 d„iy I oc51 oL ,Water Is Public Water Supply avai ble on site? ....................................... ............................... Yes No Na me _of Public liUater Supply j ;T6Wn/ViIlaae: Distance to,pi•operty from nearest wiater main Proposed well location & sources of contamination to be provided on sep raie sheet/plan. -tipp icant,Signature: VJW 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 Svo yearl 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 alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam C nty. Date of Issue Permit Iss ing Offici -�'' ' Date of Expiration l '? Title: S - Permit is Non- Transferabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well drillel� \ Form -97 Rev. 3, - Boyd Artesian Well Co., Inc TO 4 - Rte. '5 2' Carmel, N.Y. •0512. (845) 225-3196 Fax (845) 225-8420 �������� ��� � d� ��� � � �a ��) Aga -a��3 �e Vai a ri c�;, AA, r. I �J ... ... ..... . A< A r4L I I 9v ul_7l ................ 411 A< A r4L I I 9v ul_7l ................ -0 soy.d-.Artes*an.:;W..eRJC -1pAnc,-.1-----.- 1054 Rte. 52 Carmel, N.Y. 10512 (845) 225-3196 Fax (845) 225-8420 /AABILITY XAAA 'JlrY 10 1"qKg? 6koif' re rum Vol/ 1 5 ho E))2. I 11 M. - �_ -.��:_ -__yam: '\\V), 61)? Vy pop J-p'll � 4Ki- Sho2� ���s2r�`r� ,� iC