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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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WELL COMPLETION REPORT
Well Location
Street Address:
o
Town/Village:
Tax Map # a
Map Block ' Lot(s)
Well Owner:
Name: Address:
/h � (( 481q&%— ;w l Ct� lloc�r l P � 'I/ fig'
7t,4
Use of Well:
�r�Residential _Public Supply Air cond /heat pump _Irrigation
1- Primary
Business' Farm Test/monitoring —Other(specify)
2- Secondary
Industrial Institutional Standby
Drilling Equipment
Uirotary _Cable percussion Compressed air percussion Other(specify)
Well Type
_Screened Zopen end casing _ Open hole in bedrock _Other
Total Length /t.
Materials: Steel . Plastic Other
Casing Details
Length below grace =ft.
Joints: Welded Threaded Other
Seal: ement grout Bentonite Other
Diameter in.
Weight per foot Ib /ft
Drive shoe: Yes o
Liner: _Yes Wo
Diameter in
Slot Size
Length ft
Dept to Screen ft
Developed?
Screen Details
First
_Yes No
Second
Hours
Well Yield Test
_Bailed _Pumped = Compressed
Air -
Hours
Yield
gpm
Depth Date
Measure from land surface-static spec ft
During yield test O
Depth of completed well In ft.
too
Well Log
Depth From Surface
Well Diameter
If more detailed
ft.
ft.
Water Bearing
in
Formation Description
information
Land Surface
st Lions or
--
sieve analyses
are available,
please attach.
If yield was tested
Feet
Gallons
Per Minute
Pump /Storage
Tank Information
at different depths
during drilling
list:
Pump Type "Wo' apacity
Depth Model 14 Sh 7_/4A
Voltage o HP.... J
Tank. Type l6QLcrX Volume
b- i Well'com feted
!� P
•�r�l,
Well Duller PCCelrtificate;# �fNYState # ° °'.
�� /. .Date
PumpInstaller PCCertif)cate ># , y_ :NY State #1F3 d /,�
"" N% "� i�
}�of�Report ,,Y;
�i, ".T�klr
'�
ll
Well Duer Name8r 'Ad tlress u" rig` WeIIDr(Ilei st In
' .! :e 3 g fl, > eY sk'Ye P^`� �c 1 ^ r _, d� rv,. -k �� i z, _ �.rry �y °f Ye-� d i rCy f x Ms i_ sh . +Vr:I 4 i :, -i e k �r �s.s a (,p .t] ,�=.z� �^� 3i �+„' ,p£ x s s� kFx D �r M,.� a v .�K.a '�.. a�.;S� ..4 �.d.2� �� 4 d ms �w �Pum
Installer ame &> Address' `� " k�� _ ���� „ a Purri tlnstaller ` "i nature 11; „'.�
., , t >! :'�'.k a4” �' k..x .' -Y 'i�`X
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,a.. �,i 1 ,a � a ,� ,y �' �i: - r..4" i3 `y. � i i �"�Y:.� �a;{ r I ,mow � M�'�k• xG'S�t�y j��y `Y
if. : X � � ' :T_1 /.� r'•�,.:. ...aW.e�. S ..a .p 4.iN�x':.�.. ."Y...'xa�P,�.• &�.i:�:..a: .x...:� x 3.uw �,:.��:45 �Fd � �� .G �^ty��'.
1 \V G. CAMA LVIi[tUVll UI WCII Wltll UIJCatIGeS UPat least two permanent ianamarKS to oeproviaea on a separate sheet/plan.
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3106
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
TTI-V
1021dPIA-IRTMENT OF HEALTH
I Geneva Road, Brewster, New York 10509
Phone # (845) 808-1390
Fax # (845) 278-7921 -
Subject: Proposed Well Bleyer
202 Peekskill Hollow rd
(T) Putnam Valley
July 9, 2013
Dear Mr. Anderson:
XountyExecutive
jiUtajw-th6-ah6'V' te&iehc6id lot 63k V4hceint-vle Pepin; , --Public- Health-- Te6hnician.'! e
jeaionvas co e
application to drill a new well is approved with the following stipulations:
1. A Well Completion Report (WC-97) shall be submitted no later than 30 days after the well completion
by the permittee.
Please contact me at (845) 808-1390 ext. 43131 if you have any questions.
Sincerely,
Vincent Perrin
Public Health Technician
cc: VP, file
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