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PUTNAM COUNTY DEPARTMENT OF HEALTH ` V
DMSION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL / ' ,
please print or type PCHD Permit # w I 1 u
Well Location:
Street Address: Town/Village Tax Grid #
Cornwall Hill Rd, Patterson Map13 Block Lot(s) 42
Well Owner:
N
Address:
P;O, box 405 Cornwall Hill Rd. Patterson 1256
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business _ja_ Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 10. gpm # People Served Est. of Daily Usage _gal.
Reason for
XX Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) : Deepen Existing Well
Detailed Reason
for Drilling
Well Type
XX Drilled Driven Gravel Other
Is well site subject to flooding? ............ ... ..:..................... ........................................ Yes No XX
Is well located in A realty subdivision? ...................................... ............................... Yes No XX
Name of subdivision Lot No.
Water Well Contractor: Mil 1 Drilling INC. Address:75 Putnam Ave. Brewster. ' N.Y _
Is Public Water Supply available to site? .................................. ............................... Yes No XX
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on se arate sheet/plan.
Date. May 7, 1998 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 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 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. 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.
Date of Issue 5�/� ��5 Perini
Date of Expirati n Title:
Permit is Non - Transferrable
White copy HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT W- 31-.98
Well Location
Street Address:
Cornwall Hill Rd,,:
Town/Village:
Patterson
Tax Grid #
Map Block Lot(s)
Well Owner:
Name: Address:
Kessman Bros., PO Box.405, Cornwall Hill Rd.,'Patterson, NY
Use of Well:
1- primary
2- secondary
Residential Public Supply Air cond/heat pump Irrigation
Business XX Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion XX Compressed air percussion Other (specify)
Well Type
Screened Open end casing XX Open hole in bedrock Other
Casing Details
Total length 173. ft.
Length below grade 17112 ft.
Diameter 6 in.
Weight per foot 19 lb /ft.
Materials: XX Steel _ Plastic _ Other
Joints: _ Welded xx Threaded _ Other
Seal: XA Cement grout _ Bentonite Other
Drive shoe: XX 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
XX Bailed —Pumped _Compressed Air
Hours 6
Yield 8 gpm
Depth Data
Measure from land surface - static (specify ft)
55
During yield test(ft)
600
Depth of completed well in feet
.800
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
.10
Sandy loam
.10
50
Hardpan.
50
80
Brown' sand
.80
100
Gravel
.100.
.150
Soft. limestone
.150.
800
Medium to hard white limestone
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage lank Information
185
3
Pump Type �� Capacity
Depth Model
Voltage HP
Tank Type Volume
320
-
4 3 12
6'
500
6 -:3/4
Date Well Completed
6/8/98
Putnam County Certification No.
2
13m:Well
/16/98
Dril er (signature)
NOTE: Exact location o ll with distances to at least two permanent landmarks to be provided on a separate sheet/plan.
Well Driller's N DR ING, INC e� Address: 75 Putnam .Ave, Brewster, NY
Signature: Date: June 16th,. 1998
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
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I PUTNAM COUNTY HEALTH DEPT Y y 7 7 010
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