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<br />FormGW-5COMMONWEALTHOFVIRGINIADEQWell#_________ <br />Revised8/1/2016UNIFORMWATERWELLCOMPLETIONREPORTUSGSLocal#_________ <br />U21538451112 <br />Page1VDHHDIN#_________ <br />VDHPWSID#_________ <br />WellAbandonmentForm <br />(Forusewhenoriginalwellcompletionreportisunavailable) <br />U21538451112 <br />Welldesignation,NameorNumber:_________________________________________________________________ <br />1.ContactInformation <br />Contact:NameAddressPhone <br />OPSUIFSOWB/SFHJPOBMQBSLBVUIPSJUZ <br />6511PYSE/GBJSGBYTUBUJPOWB/3314: <br />Owner <br />WBMMFZESJMJOHDPSQ/QPCPY715VQQFSWJMMFWB/312:6651.6:3.434: <br />Driller <br />SystemProvider <br />2.WellLocation <br />BMHPOLJBOQBSLMPVEPVO <br />PhysicalAddress:County/City: <br />BMHPOLJBOQBSL <br />SubdivisionName:Section:Block:Lot: <br />128.4:.9:94 <br />TaxMap/GPIN#: <br />4:+14(54/88#88+34(38/:4 <br />Latitude*:NLongitude:W <br />Horizontal:WGS84NAD83NAD27 <br />DatumSource <br />5 <br />Lat/LongSource(CheckOne):MapGPSPPDGPSSurveyImageryWASS <br />MFXJTMJOFCVSH <br />LocationInformationCollectedBy: <br />JOXPPETCFIJOEMBVOSZ <br />PhysicalLocationDescription: <br />3.WellConstruction <br />3.27.333.27.33 <br />DateStarted:DateCompleted: <br />56( <br />StaticWaterLevel(unpumpedlevelmeasured):ft. <br />5 <br />CasingSize(I.D.)andMaterials:7#TUFFM CasingPulled:YesNoUncasedWell <br />DepthofFill:TypeandSourceofFill: <br />1CFOUPOJUF <br />211 <br />Grout:FromtoType:FromtoType: <br />MFGUDBTJOHJOUIFHSPVOE <br />Methodofpermanentlymarkinglocation: <br />TypeofFacility(CheckOne): <br />TypeofUse(CheckAllThatApply): <br />55 <br />PrivateDrinking/DomesticUseAgriculturalFoodProcessing <br />WaterworksManufacturingIrrigationInjection <br />Observation/MonitoringWellGeothermal(Cooling/Heating)FireSafety <br />Closed <br />Open:ReturnedtoSurface <br />ReturnedtoAquifer <br />4.Disinfection <br />5 Date: <br />22.26.32 <br />WellDisinfected:YesNo <br />5.Certification <br />Icertifyunderpenaltyoflawthatthisdocumentandallattachmentswerepreparedundermydirectionorsupervisioninaccordancewithasystemdesignedtoassure <br />thatqualifiedpersonnelproperlygatherandevaluatetheinformationsubmitted.Basedonmyinquiryofthepersonorpersonswhomanagethesystemorthosepersons <br />directlyresponsibleforgatheringtheinformation,theinformationsubmittedistothebestofmyknowledgeandbelieftrue,accurate,andcomplete.Iamawarethat <br />therearesignificantpenaltiesforsubmittingfalseinformationincludingthepossibilityoffineandimprisonmentforknowingviolations. <br />Ejhjubmmz!tjhofe!cz!Mfxjt!Mjofcvsh! <br />Mfxjt!Mjofcvsh <br />Ebuf;!3129/13/26!25;28;62!.16(11( <br />2.4.33 <br />Signature:_____________________________________Date:___________________________ <br />382:111392 <br />LicenseNumber:______________________________________ <br />