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Well/Water System Construction Permit Page 1 Of <br />Loudoun County, Virginia Health Department <br />Division of Environmental Health ldentificatlon Number fl A t T <br />777 -0234 Metro 478 -8408 (9 Map deference <br />General Information IV' '71, 14 11�) <br />New ❑ Repair ❑ Abandonment K Upgrade ❑ Well ID.# W k•%/ A /'• /// 1 — y% Z 1-1 <br />Based on the application for a well /water supply system construction permit filed in accordance with Chapter 1040, Codified <br />Ordinances a construction permit is eby issued to: <br />Owner LL A �- �'• Telephone U 3 — 4- _ <br />Addresses CL) � 3 �v! b <br />I For a well /water system which is to be constructed on /at ©A.) / <i JJ J+ <br />/r, Lt) C.s _F_ < P1ud. %/Y4" ) Tii2,, -13ktf 7lfly FA 0,,,h <br />Subdivision <br />Section /Block �� Lot <br />DESIGN I NOTE: INSPECTION RESULTS <br />Water supply, existing: (describe) <br />To be installed: class P N'1�1 4 ' %r " "�- <br />Cased and Grouted to Bedrock plus 10' or a minimum <br />cased Grouted hichever is greater <br />Well Location See Page '-- <br />I. If well yield as determined by 30 minute airlift test is less <br />than 5 gallons per minute, a pumping test must be performed <br />as follows: <br />A. Pump and related equipment shall be installed and <br />the static water level measured. <br />B. Pumping shall begin at a rate of withdrawal greater <br />than 5 GPM until water level drops to a point close <br />to bottom of the well. <br />C. At this point, the pump rate shall be adjusted so <br />the water level remains constant <br />D. Measure and record the volume of water discharge <br />and water level (electric tape) at 15 minute intervals <br />throughout the test <br />E. Discharge water at least 50 feet from the well and <br />sewage disposal area. <br />F. Interruption of pumping longer than 15 minutes <br />shall require extending the pumping time that <br />amount of time. <br />The well /water *ystem is to be constructed as specified <br />by the permit �$"�.�' attached plans and specifications O. <br />This water system construction permit is null and void if <br />(a) conditions are changed from those shown on the <br />application (b) conditions are changed from those shown <br />on the construction permit <br />Water supply location: Satisfactory yes ❑ no ❑ <br />Drillers Report (G.W.2) Received yes 0-'no ❑ <br />Well Construction Approval yes ❑ no O <br />Sanitarian �'>� Date <br />Well Driller t J Lic tt <br />Pump Installer <br />Lic 8 <br />Chemical Quality Data Received yes ❑ no O N/A ❑ <br />Pumping Data Received yes ❑ no O N/A ❑ <br />As built sketch on page <br />Bacteriological Sample Received yes ❑ no ❑ <br />Water System Approved yes ❑ no ❑ <br />Sanitarian Date <br />II. Criteria for approval of well and well yield are as <br />follows: <br />The well must produce a: <br />A. Minimum of 1 gallon per minute for 6 continuous <br />pumping hours after the well has been pumped <br />out according to Part I, Sec. B of this permit <br />B. The pump test can be terminated early and well <br />yield considered adequate it <br />1. The well cannot be pumped out as stated in <br />Part I B of this permit <br />2. The Well yields 2.5 gpm or greater for 3 hours <br />of continuous pumping after Part I B of this <br />permit is completed. <br />C. Sufficient storage and yield may be considered for <br />approval. <br />D. Person conducting the pump test shall collect a <br />sample to be analyzed for constituents described <br />in Codified Ordinances of Loudoun County Title <br />4, Chapter 1040, Appendix III. <br />E. Replacement wells are exempt from this <br />requirement <br />Date: �U' •� "7' � Issued by: <br />L , z .i This Construction <br />Permit Valid until <br />Date: < <" /Ce Reviewed b (V .r 7 <br />suv.�w.«y swlanan <br />Original / Health Department Copy / Applicants Copy <br />r-0 e�'4 <br />,Z-r rte <br />