WWIN-1988-0702 - Laserfiche WebLink

Record Of Inspection—Nonpublic Drinking Water Supply System Commonwealth of Virginia Use of form required only when Health Department De artment of Health water supply constructed in con- Department on- I.D. Number p junction with an on-site sewage disposal system, or when FHA, VA financing is involved. Map Reference F.H.A. or V.A. Case Number If Applicable Date Local Health Department Owner Address Phone Exact Location of Premises Subdivision Section/Block Lot Class of nonpublic drinking water well. 1) Class Ill A. (drilled well) ❑ 2) Class III B. (bored well) 0 3) Class III C. (jetted well) ❑ 4) Class III D. (dug well) ❑ 7 Date of installation '` 5) Other E. [) CONSTRUCTION INFORMATION If information in any item below is secured from other sources (i.e.) well log, etc., so note. 1. Water well completion repert filed as required by 18.02.07. Yes ❑ No ❑ 2. Well Location: Distances from sources of pollution (see Table 12.1, Minimum Separation Distances) and Section 10.04.01 and 18.02.02. Building Sewer Pretreatment Unit Conveyance System Subsurface Soil Absorption System (nearest point). Property Line Other Site graded where necessary to divert water away from well? Yes ❑ ❑ No n.a. C3 3. Construction, General: (see Section 18.02.05, and 18.02.02) Total depth of well feet. Type of casing . Depth of casing feet. Diameter of casing inches. Casing extends inches above ground . Exterior space around casing sealed with neat cement grout to a depth of feet. Screens constructed of free of rougfi edges and irregularities, with positive watertight seal between screen and casing? ❑ yes no ❑ n.a. Et-Well head and opening to the interior protected? yes Er no ❑ Type of well seal Pitless adapter used? yes .E] no ❑ n.a. ❑'Properly installed? yes ❑ no ❑ n.a. ❑- -Proper venting? yes ❑ no ❑ n.a. ❑--- 4. Quantity: Yield and drawdown determined by continuous pumping of _ hours. Drawdown feet. Yield GPM. Type of storage 5. Quality: Sample tap provided at entry into system? yes ❑ no ❑ Sample(s) collected? yes ❑ no ❑', Results of samples. Satisfactory ❑ Unsatisfactory ❑ (attach copy of results to this form) Based on the inspection of this water supply system and the information contained on the water well completion report attached, this water supply is approved. ❑'' Remarks: Date Signed Sanitarian Date Signed Supervisory Sanitarian Date Signed C.H.S.204 Rev.4/83 Regional Sanitarian (If V.A.or F.H.A.)