WWHP-2011-0106 - Laserfiche WebLink

'iiWNER: DEQ WELL # USGS LOCAL # 9. Sta te law requires submitting to the Virginia State Water Coniro{ boara information about ground water and vv2!Is for every well made in the State intended for water,' ater, or any other non - exempt well. This information must be submitted whether the well is completed, on standby, or abandoned. Information required includes: an accurately and completely prepared water well completion report, full data from any aquifer pumping tests, drill cuttings taken at ten foot intervals (unless exemption is secured), the results of any chemical analysis, and copies of the geophysical logs. Quarterly pumpage and use reports are required from owners of public supply and industrial wells. County or State permits to drill may be required in some parts of the state Some counties require submission of a water well completion report. The Virginia State health Department requires a water well completion report for public water supply. riller's Log (Use additional sheets if necessary) i 11 12. Diagram of Well Construction 'Depth (feet) Type of Rock or Sod - -- - -- (with dimensions) . _ � Remarks Drilling ...................... From TO (Color material fossils. hardness. etc.) es ( Time VVater, caviny caviti. (Min.) -— broken, core. shot, etc ) i 1 1& lZe./ ell 13. vWeii Lot !dedicated? - Size ft. by ft. Well (louse? Distance to nearest pollutant source ft. Type Distance to nearest property line - ft. Building _ ft 14. WATER SERVICE PIPE: Checked under Pipe Size _ in. Material - P s.i. for minutes Installer - Liate - - - 15. l certify that the information contained herein is true and correct and that this well and/or system has been installed and constructed in accordance w; h the requirements for well construction as specified in compliance with, appropriate county or independen ,i o 'inane and the laws and rules of the Commonwealth of Virginia. Signature _ . _._ .. — - -- Date (Well do leei-o�r authorized person) License Number ` -IR CK