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04363
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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WELL COMPLETION REPORT
Well Location
Street Ad ress: fl��
Town/Village:
Tax Map #
Map Block Lot(s)
"GPS ,1a
Well Owner:
Name: Address:
/
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
_ otary _Cable percussion _Compressed air percussion_Other(specify)
Well Type
Screened L pen end casing r Open hole in bedrock Other
Casing Details
Total Length
Length below grade aft.
Diameter 41 in.
Weight per foot /.5 1b/ft
Materials: teel Plastic Other
Joints: Welded ✓ Threaded Other
Seal: vCement grout Bentonite Other
Drive shoe: Yes l�
Liner: _Yes "o
Screen Details
Diameter in
Slot Size
Length (ft)
Dept to Screen ft
Develo ped?
First
_Yes No
Hours r
Second
Well Yield Test
_Bailed _Pumped VCompressed Air
Hours
Yield 1 gpm
Depth Date
Measure from land surface-static spec )
30
During yield test ft
Dept o compete we I in ft.
�Oc�
Well Log
If more detailed
information
descriptions or._,...
sieve analyses
are available,
please attach.
Depth From Surface
Water Bearing
Well Diameter
in
Formation Descri tion
ft.
ft.
Land Surface
/0,%S
b
p U� .4 /" 0 e /V
to 3
� oo
_ _
ry :.,
e. _ .
'
If yield was tested
at different depths
during drilling
list:
Feet
Gall9n, Pe Minute
Pump /Storage
Tank Information
"� �`�'` ' '
Pump TypeB knle4S FUe Capacity !2).
Depth Model .S_
Voltage 3y HP r /Z
Tank Type t,r Ir S—b Volume
Date U,,iI%;.' ll "com' "feted
�#
r i 4
� �
% ��'
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1Nell Dhil" 3
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PG Ce'rt�ficate # ' ` (� �
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y:, K' � lie �:�i:� i
PC Certiftcate #� U
w .......... L.
NY Staten# $ %
Date of Report ` AK s.i ' ;'
u..:x
fit- ai r1y; .. ��jH Fryr l.. l�i A•�
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NOTE: Exact Location of well with distances to at least t*o permanent landmarks to be provided on a separate sheet/plan.
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -9T
Rev. 3/06
YML ENVIRONMENTAL SERVICES
321 Kear Street
/orktown Heiqhts, N.Y. 10598
7j;.����,/�«�;�'��
Albert H. Padovani, Director
LAB #: 1.704476 CLIENT #: 60299 NON STAT PROC PAGE: 1 of 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
HADDOCK, THERESA
194 PEEKSKILL HOLLOW RD
PUTNAM VALLEY, NY 10579
SAMPLING SITE: 194PEEKSKILL HOLLOW RD
: PUTNAM VALLEY, NY 10579
COL'D BY: ANTHONY ORTIZ B
NOTES...: BASEMENT ENTRY POINT
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
08/08/07 MF T. COLIFORM
RESULT
ABSENT /100 ML
DATE/TIME TAKEN: 08/08/07 07:15
DATE/TIME REC'D: 08/08/07 01:40
REPORT DATE: 08/09/07
PHONE: (845)-528-2215
SAMPLE TYPE..: POTABLE
PRESERVATIVES: NONE
TEMPERATURE..: < 4C
COL7FORM METH: MF
-------------------------------
NORMAL - RANGE
ABSENT
METHOD
SM 18-20 9222B
COMMENTS: `
MFTC THESE RESULTS INDICATE THAT THE WATER AS NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDINC���-THE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION.
Av
SUBMITTED BY:
Albert H.-Q'a---TAovan1i-,. M.T. (ASCP)
Director`~ ELAP# 10323
ii•
1 �
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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WELL COMPLETION REPORT
Well Location
Street Address-
lq,� D
Town/Village:.
V u 11
Tax Map #
Map Block Lot(s)
Well Owner:
Name: Address: rr // //
ngAa A � � e e /� cf 441 /7T1 11 dW U^ e
Use of Well:
1- Primary
2- Secondary
AAResidential _Public Supply Air cond /heat pump _Irrigati n
Business Farm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equipment'
_Rotary _Cable percussion Compressed air percussion Other(specify)
Type
pen
_Screened pen end casing _ Open hole in bedrock _Other
__W
Casing Details
Total Length L- f-
Length below grac7e'_�5ft.
Diameter -in.
Weight per foot lb /ft
_
Materials: " teel Plastic Other
Joints: Welded Threaded Other
Seal: ement grout Bentonite Other
Drive shoe: Yes I--No
Liner: _Yes _No
Screen Details
Diameter in
Slot Size
Length ft
De t to Screen ft
Develo ped?
First
I
No
Hours
Second
--d—Yes
I
Well Yield Test
_Bailed _Pumped Compressed Air
Hours f"-
Yield / 0 gpm
Depth Date
Measure from land surface-static (specify ft)
30
DDuring yield test
Depth of completed well In ft.
3aa
Well Log
If more detailed
information
descriptions or.
' sieVe�analyses'` � •
are available,
please attach.
. Depth From Surface
Water Bearing
Well Diameter
in
Formation Description
ft.
ft.
Land Surface
A
v v �,✓
a•o
_ ,.
b- 5��1JV►r.
� •
If yield was tested
at different depths
during drilling
list:
Feet
Gallons Per Minute
Pump /Storage
Tank Information
Pump Type Sk t�►,crs 0: Capacity_
Depth --Z Model / "
Voltage �i �� _ HP )-
Tank Type W �` aps Volume /�
v
Date Well Completed u
':'� P :,'A"S �.
'.h! '� .� �, +i F' � j,,�:
3'LL'F t `�.•.Y
1Nell Driller, PC Certiftcate#, ; Y _ P�;zNY�Stateh#
STM' �� - S �� � C
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RurnpInstallerxPC `'Certificate: ° #k `� ;L�B�;°�'.
r
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Pu Instal RAJ me & iAddress'nxf , b� "a
.0 i , 4,
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NU i t: txact Location of well witn distances to at least two permanent landmarks to Abe proMed on a separate sheet/plan.
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3/06
YML ENVIRONMENTAL SERVICES
a 321 Kear Street
Yorktown Heights, N.Y. 10598
(914) 245 -2800
• ;AJbert ;�s1r •F?�.�.���-n =i•;•. D4:•r����r- - , _� .:; .., r :� _ . -,: , .�-- �-;z.: ,
LAB #: 1.704476 CLIENT #: 60299 NON STAT PROC PAGE: 1 of 1
HADDOCK, THERESA DATE /TIME TAKEN: 08/08/07 07:15
194 PEEKSKILL HOLLOW RD DATE /TIME RECD: 08/08/07 01:40
PUTNAM VALLEY, NY 10579 REPORT DATE: 09/21/07
PHONE: (845)- 528 -2215
SAMPLING SITE: 194 PEEKSKILL HOLLOW RD SAMPLE TYPE..: POTABLE
: PUTNAM VALLEY, NY 10579 PRESERVATIVES: NONE
COLD BY: ANTHONY ORTIZ B TEMPERATURE..: < 4C
NOTES...: BASEMENT ENTRY POINT COLIFORM METH: MF
DATE FLAG PROCEDURE RESULT NORMAL — RANGE METHOD
08/08/07 MF T. COLIFORM ABSENT /100 ML ABSENT SM 18 -20 9222B
COMMENTS:
MFTC THESE RESULTS INDICATE THAT THE WAT S NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDI E NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION.
SUBMITTED BY: �--- l m
Albert H. do ni, M. .(ASCP)
Director
ELAP# 10323
PUTNAM COUNTY DEPARTMENT OF HEALTH
a IVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print or type $CHD.PermltA.
Welilocation: ..
Sheet4&,.J$ Ad ,. ss:- .. Town/Village Tax Grid #
rLP-- Pv A 1� I)O NT Map jpUBlock 2-1-Lot(s)/3
Well Owner:
N e: S
Address: ,Q
Use of Well:
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 gpm # People Served Est. of Daily Usage *A ! gal.
Reason for
v7Replace Existing Supply Test/Observation Additional Supply
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? ........P. ...................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor: ly, , j$-1).P C� ,S'd Address: &Pt" 92-45 �- ;kfzaw1 al
Is Public Water Supply available to site? .......... yI. 6- � ............ ............................... Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on s sheet/plan.
Date: �� pplicant Signature:
..:z: Aj41
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 16rof they ?"
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code androvidwed
that,within thirty (30) days of the completion of water well construction, the applicant or their designated t-,
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance vh th rri
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on orm ::O X �
provided by the Putnam County Health Department. During all well drilling operations, the applictt an?g6�
well driller shall take appropriate action to assure that any and all water and waste products from stwh
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 two years 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 Public Health Director. revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water ell iller c ified by Putnam
County.
Date of Issue jli Permit Issuing cial:
Date of Expiratio Title:
Permit is Non - Transfer •a 1
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
041111 O I R) \IE 119 1 D1 I"N"I)IaI1 a I FS (I >I a III 01I f!I
DffVffSII (DN (DIF IENWRONM ENTAL HEALTH S ERWCCIES
please print or type
TO 'ABAN> 0 A WXT>ER WELL
PCHD PERMIT #
Well Location:
Street dress:
T Nillage T Gri #
Welll ®wyne>r:
amen j
(Address:
Well Type:
V Drille Driven Dug Gravel Other
Depth Data:
p
tv
Well D th ft
Static Water Level ft
Date Measured
Use of Well:
Residential
Public Supply Air /Cond/Heat Pump Abandoned
I- primalry
Business
Farm Test/Observation Other (specify)
2-secondary
Industrial
Institutional Standby
Water Well
Contractor:
Name: , Address:
Reason F®Ir
J� ' fleL !✓
„6,�✓
Abandonment:
—
Description of Work To Be Performed:
Date 3 Applicant Signature: x'
P ERMff 1'
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
submit to the Department a certified statement that the inf a ion deli7ted on the application for this
permit has been completed. ; /' n
Date 6f Issue
Permit Issuing Official
N
Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
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