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COMMONWEALTH OF VIRGINIA <br />WATER WELL COMPLETION REPORT <br />(Certification of Completion/County Permit) <br />C' -qty/City: Loudoun <br />County/City Stamp <br />Owner: Peak Investments LLC <br />Well Designation or Number: <br />Address: P.O.. Box 228 <br />Clarksville Md. 21029-0228 <br />Phone: (410)365-0414 <br />Drilling Contractor: Groundwater Systems, Inc <br />Address: 3159 Mary Etta Lane <br />Herndon, Virginia 20171 <br />Phone: (703) 620-2040 <br />Well Location: 14280 Mountain Road <br />PIN # 445256134000 <br />Date Started : 02105108 Date Completed: <br />1. WELL DATA: New X Worked <br />Deepened <br />Total Depth: 400' <br />Depth of Bedrock: 22' <br />HOLE SIZE (Also include reamed zones) <br />10" inches from 0 to <br />60' <br />ft. <br />6" inches from 60' to <br />400' <br />ft. <br />inches from to <br />ft. <br />CASING SIZE (I.D.) and material: <br />6 inches from +2 to <br />61' <br />ft. <br />-Material: Steel <br />Wt. Per foot: 131b. or wall thickness <br />.188 <br />in. <br />inches from to <br />ft. <br />Material: <br />Wt. Per foot: or wall thickness <br />in. <br />inches from to <br />ft. <br />Material: <br />Wt. Per foot: or wall thickness <br />in. <br />SCREEN SIZE and mesh for each zone <br />(where applicable) <br />inches from to ft. <br />Mesh Size Type <br />inches from to ft. <br />Mesh Size Type <br />inches from to ft. <br />Mesh Size Type <br />GRAVEL PACK <br />From To ft. <br />From To ft. <br />GROUT <br />From 60' To 0 ft. Type Pressure Tremmie <br />From To ft. Type Pressure Bentonite <br />SWCB Permit <br />County Permit <br />T80079650002 <br />Certification of Inspecting Official: <br />This well does does not <br />meet code/low requirements. <br />S <br />Date <br />For Office Use <br />Tax Map ID No. 16111411112 <br />Subdivision <br />Section <br />Block Lot #1 <br />Class Well: I _ IIA _IIB _IIIA _ <br />IIIB X IIIC 11113 IIIE IV <br />02106108 Type of Rig: Rotary <br />2. WATER DATA: Water Tempature degrees. <br />Static water level (unpumped level measured) ft. <br />Stabilized meas. pumping water level ft. <br />Stabilized yield 3.5 gpm after hours. <br />Natural Flow: Yes X No Flow rate gpm. <br />Comment on Quality: Clear <br />3. WATER ZONES: <br />From <br />165 ft. <br />1.5 gpm. <br />From 295 ft. <br />2 gpm. <br />From <br />- <br />ft gpm. <br />From ft. <br />gpm. <br />From <br />ft gpm. <br />4. USE DATA: <br />Type of Use: <br />Drinking X Livestoc_k_ Watering <br />Irrigation <br />Food Processing Household X <br />Manufacturing <br />Fire Safety _ Cleaning _ <br />Recreation <br />Aesthetic Cooling or Heating _ <br />Injection <br />Other <br />Type of Facility <br />: Domestic X Public Water Supply <br />Public Institution Farm Industry <br />Commercial <br />Other <br />5. PUMP DATA: <br />Type Rated HP <br />Intake depth <br />Capacity at head <br />6. WELLHEAD: Type well seat <br />Pressure Tank gal Loc <br />Sample Tap Measurement Port <br />Well Vent Pressure Relief Valve <br />Gate Valve Check Valve (when required) _ <br />Electrical Disconnect Switch on Power Supply <br />7. DISINFECTION: Well Disinfected: Yes - No_ <br />Date Disinfectant Used <br />8. ABANDONMENT (where applicable): Yes _ No _ <br />Casing Pulled Yes No Not Applicable <br />Plugging Grout From To Material <br />From To Material <br />