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Form GW -2 <br />Revised 71Z1 /0,, <br />Virginia Dept. of Environmental Quality <br />P.O. Box 1105 <br />Richmond. VA 23218 <br />COUNTY i CI T Y <br />Virginia Plane Coordinates <br />N <br />- E <br />Latitude S Longitude <br />IDaturn: <br />Topo. Map No. - <br />Elevation ft. <br />Formation <br />Lithoiogy <br />River Basin <br />Province <br />Type Logs - - - <br />Cuttings <br />Water Analysis <br />Aquifer Test <br />COMMONWEALTH OF VIRGINIA <br />WATER WELL COMPLETION REPORT <br />tC ct'iiiiraii,n! ��t t- 'trni�le{i��tt C t�uni� I'�rnti[i <br />Owner Cllal,-Ilt 1-4 c. -.� <br />Well Desl nation or nu Aber <br />1LI,Ir.., twoo4S <br />its •3- r. / / �.�� �•- >). <br />GI � r&V4 ► (A'�ao (, (-7 <br />Phone <br />DEQ WELL b <br />USGS LOCAL # <br />DEQ Permit <br />County Perini <br />WV81D No <br />Certification of inspecting off!ciai <br />This Viet) does does not <br />Meei code.law iequiremenrs. <br />Signature <br />Date <br />F0, Office t, r c- <br />Tax Map. i -. ,, . 8";'t CkZ2 � <br />Subdivision OL <br />Section !/ <br />q Blnck <br />� I <br />Drilling Contrartor � t' -i-f e loll �., �', v� -,5/1O <br />\(ILIrCSa LAl"✓C f 0111-t. Class Well 11A <br />/ 118 MA IIB <br />P! one <br />P,0 60f ` �� lilt - ilif) Ili <br />VFL_ LO CAT'C;v <br />(. (direction) of <br />°r d 52C'77p ft� (feet'Irtiles;0 �% <br />(direction) of <br />f possible please include map showing marked well location. <br />)ate Started Date Completed Type Ric; <br />1. WELL DATA: 'ev X <br />Total Depth <br />Reworked Deepened <br />2. WATER DATA: Water Temperature F <br />Depth to Bedrock <br />_�i- - <br />ft. <br />Static Water Level (unpumped level measured; ft <br />.2 <br />Hole Size (Also include raamed zones) <br />ft. <br />Stabilized measured pumping water level ft. <br />inches from <br />to t g <br />ft. <br />Stabilized Yield - _ gpm n after - ,,,1rs <br />Natural Flow Yes <br />s" inches from <br />_ _ <br />to 3 % a <br />ft. <br />No F1cw Rate gpm <br />Comment on water quality: <br />inches horn to <br />Casing (I.D.) and Material <br />ft <br />3. WATER ZONES: From To <br />rSSize <br />pEh;rcm — <br />P <br />- - to S`. <br />ft. <br />From TO ��_ <br />From To From To <br />Material j <br />- -� - <br />- <�. !-ror,� To <br />1 <br />Weight per tt <br />or wall thickness <br />in. <br />4. USE DATA <br />Type of Use. Drinking LiVtvStU. ^.k YJater,r�g <br />P,!la,enal <br />t <br />-- - -- -- <br />Irrigation Food Processing Household <br />Weight per ft <br />or wa!I thickness <br />in <br />Manufacturing Fire Safety Cleaning <br />Recreation Aesihetic (:oolinglHeatirig <br />inches from <br />to <br />ft. <br />Injection Other <br />Material <br />vVeight per ft <br />or wall thickness <br />in. <br />Type of Facility: Domestic Public Water Supply <br />Screen Size & Mesh for Each <br />Zone <br />Public Institution Farm Industry <br />inches from <br />esh Size <br />.1! <br />_ _ to s _ <br />ft <br />Coll-Iniercial _ Other <br />5. PUMP DATA: Type <br />yp Rased tip <br />Type - - <br />to <br />- <br />ft. <br />_.. <br />Intake Depth ft. Capacity gpm at i!,-p-f <br />6. WELLHEAD: Type of tJfeil Seal <br />Mesh Size <br />Type <br />Pressure Tank gal. Location <br />inches from - <br />Mesh Size <br />to <br />Type <br />ft. <br />- - <br />Sample Tap Measurement Port <br />-- - -- - -- - -- <br />inches from <br />-- <br />to <br />r:. <br />Well Vent Pressure Relief Valve <br />Mesh Size - <br />- <br />Type <br />Gate valve Check Valve (when required) <br />Gravel Pack <br />Electrical Disconnect Switch on Power Supply <br />From to <br />;� <br />7. DISINFECTION: Well Disinfected Yes No <br />to <br />ft_ <br />� t <br />La•o Disinfectant .'serf <br />From <br />Grout <br />Amount Hours Used <br />o <br />From 3 t.:, <br />n 1� <br />� "`� ` <br />8. ABANDONMENT: (where able) Yes No <br />From to <br />it ype,1» <br />ft Type <br />C <br />Casing fulled Yes No NA <br />Plugging Grout From to Material <br />