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DEPARTMENT OF HEALTH
1 ivi 'on Of Environmental Health.Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
BEET ADDRESS: WN7V0. ! I Y TAx GRID NUMBER:
f�fL� .�?IJ•?T.E --q a
WELL LOCATION
WELL OWNER
NAME: ADDRESS: w1-1iiE 1-f311V,5; A/, V
.r14m,5.S /-jln o o l o 1140 A1,4M4,eoA1, c,1< 4 VE.
jg PRIVATE
❑ PUBLIC.
USE OF WELL
1 - primary
2 - secondary
WRESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND -IHEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED /EST. OF DAILY USAGE �Odgal.
REASON FOR
DRILLING
9 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION
❑REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
I WELL DEPTH �D ft.
STATIC WATER LEVEL ft.
DATE MEASURED `31'
DRILLING
EQUIPMENT
❑ ROTARY IlrCOMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑, CABLE PERCUSSION O OTHER (specify):
WELL TYPE
1 ❑ SCREENED ❑ OPEN END CASING, WOPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH 6 ft.
MATERIALS: W STEEL O PLASTIC ❑ OTHER
LENGTH.BELOW GRADE a9 ft.
JOINTS: ❑ WELDED 20 THREADED ❑OTHER
DETAILS
DIAMETER 4a in.
SEAL: 9CEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT Z lb-/ft-
DRIVE SHOE 5KYES ❑ NO LINER: ❑ YES t9NO.
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑ YES 0 NO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ No
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST It If detailed pumping
METHOD: O PUMPED i tests were done is in-
SK COMPRESSED AIR , formation attached?
8AILED O OTHER ; ❑ YES ❑ NO
It more detailed formation descriptions or sieve analyses
LOG are available, lease attach.
NWELL
ROM
CE
water
B
ing
Well
Dia-
meter In
FORMATION DESCRIPTION
CODEO
It.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
9Gn►•
Land
Surface
SCIi1�/ C/r V-iJr7�t°i
19
Sof 46:�Pl
Seem
3
WATEP O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL:
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME t30 y OAT 20
ADDRESS 2— SIGs fR/+
//WV,
DEPARTMENT OF HEALTH
Division of Environmental Health Services
3pIQ,� TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
3 APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street A dress
ColrkeA - e
�r
`�-
Town /Village /City Tax
ci �rS d V1
Grid Number
WELL OWNER
Name
70- C�l
I i 6cl
Address ' di Private
e ��I" -- O Public
USE OF WELL
1 - primary
2 - secondary'
%RESIDENTIAL
O BUSINESS
G INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
O ABANDONED
❑ OTHER (specify;
O
AMOUNT OF USE
YIELD SOUGHT
,Sr gpm /#
PEOPLE SERVED 5- /EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
U)NEW SUPPLY
O REPLACE EXISTING SUPPLY
❑PROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
'
/ ��� ��
BSc_ d Vim.
WELL TYPE
MR
DRILLED
13DRIVEN
E]DUG
EI
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
Boyd A, teslan y ,
WATER WELL CONTRACTOR: Name ('Rn _ Rnute 52 aoZS c%lq Address:
IS PUBLIC WATER SUPPLY AVAILABLLN( MTE YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON REAR OF THIS APPLICATION [!]ON SEPARATE SHEET
k �j
(date) I
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.
Date of Issue: 19�,,.�
Date of Expiration: �� �9 ermit Issui
Permit is Non - Transferrable
:.
1;40 04)
Boyd Artesian Well, Co., Inc.
R. D. No. 5, . Rte. 52
Carmel, N.Y. 10512
(914) 225-3196
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