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Home My WebLink About0114DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -1 -41 BOX 2 LA J F ` - 63 00114 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Stree Address: !r d T Village: q #e- ry' o I'x Tax Grid # IMap?.0 Block Lot(s) UIJ Well Owner: Nam Address: 0 Q h d U & �c` fr t. f 0 %v 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 -� Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft.. Length below grade f ft. Diameter in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _hC Cement grout _ Bentonite Other Drive shoe: Yes No Liner _ Yes . No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test Bailed _ Pumped Compressed Air Hours Yield 10 gpm Depth Data Measure from land surface - static (specify ft) During yield test(rft) 1-0 1 Depth of completed well in feet ),�r 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 717 JL 41, If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Comple d (0 1 Putnam County Certification No. /0 Date of Re rt VW/0 Well r' r (signatur NOT Ex Act location of well with distances to at least two permanent landmarks to be provided on a sepa"rate sheetJplqpy l(>r G4e6C -eV I Well Driller 's N@LWi V 4 - Address: lk&Y La t- Signature: Date: p White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # ld Well Location: Street Address: Town/Village Tax Grid # '17- 0, 0 d�('- t1 5 ��" MaR3 JC3 Block Lot(s) -% Well Owner: Name: - 1101 -- ftN Address: a4' -Pr+� tiv 0 U A-t.l rQ . - 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 _gal. Reason for Replace 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? ...................................... ............................... Yes No ;;7 Name of subdivision 6 , Lot No. e Water Well Contractor: Wa-at E, w Address: 16 9, 0, 1G�- Is Public Water Supply available to site? ......................:........... ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: tv Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: �6 Applicant Signature: 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 Department. During all well drilling operations, the applicant and/or well driller shall Make 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 two years from the date issued unless construction of tkle 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. J 11 - Date of Issue z o U Permit Iss ng Official: Date of Expiration I Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owne A Orange copy - Well driller Form WP -97 1.10 WRA GG WELL DRILLING PUMP SERVICE LLC 1.62 Baker Road Rosburv, CT. 06783 860 -354 -1989 - 800- 303 -3097 I As set forth under New York State Environmental Conservation Law, Section 15 -1525 Wragg Wells & Pump Service LLC Registration# NYRD10140 is hereby registered with the Commissioner of the State Department of Environmental Conservation to drill or repair water wells in the estate of New York only when supervi ,5ed on - ,site by an individual who is exam certified in the respective water well activity. In accordance with the law and prior to commencement of drilling of any water well or well, registrant shall file a preliminary notice with the Department. Qegi ,strant i6 required, upon completion of the drilling of any well(6), to file a completion report with the Department giving the log of the well, the size and depth thereof, the capacity of the pump or pump,5 attached or to be attached thereto, and Such other information pertaining to the withdrawal of water and operation of completed well(5) a6 the Department by its rulea and regulation8 may require. The registration number granted by this certificate must be d 6played on the well drilling machinery of thi,5 reentrant. Notice is hereby given that all activitie& authorized by thi,5 certificate are 64 ect to the provi ,sion,s of Article 36-11 of the New York estate General Bu8ines8 Law. Registrant: Wragg Wells & Pump Service LLC 162 Baker Rd Roxbury, CT 06783 -1318 Issue Date: March 18, 2005 Expiration Date: March 31, 2006 Authorized By: Sandra Allen, Director Division of Water Putnam County Plumbing /Mechanical Trades Boards Pump Installers License 2006 David Wragg D.O.B 08/28/54 Height 6'0" _ Hair Blonde Wragg Well Drilling &Rump SerV. 162 Baker Road Roxbury, CT 06783 License No: 019 -06 Chairman, Peter Pryschlak Expires On : 12/31/2006 r