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Well/Water System Construction Permit Page _I_ Of <br />Loudoun County, Virginia Health Department <br />Sv (F <br />Division of Environmental Health Identification Number T- <br />Map Reference <br />777 -0234 Metro 478 -8408 r aaafl000aoaooaZ- <br />General Information <br />New El Repair❑ Abandonmen t Upgrade El Well ID.# <br />Based on the applicati a /water supply system construction permit filed in accordance with Chapter 1040, Codified <br />Ordinances, a construction permit is hereby issued to: <br />Owner Telephone ,p <br />Address <br />I For a well /water system which is to be cons ted on /at <br />Subdivision Section /Block AS Lot IC- <br />DESIGN <br />I NOTE: INSPECTION RESULTS <br />0 i <br />Water supply, existing: (describe) <br />Water supply location: Satisfactory yes ❑ no ❑ <br />Drillers Report (G.W.2) Received l ,fq.n"es Ili no O <br />To be installed: class <br />Cased and Grouted to Bedrock plus 1 or a minimum <br />Well Constructipn Approval yes ❑ no O <br />AM A <br />cased Grouted whichever is greater <br />Sanitarian Date <br />fh <br />Well Location See Page <br />Well Driller ° �► Lic # <br />Pump Installer Lic # <br />ZI <br />I. If well yield as determined by 30 minute airlift test is less <br />Chemical Quality Data Received yes ❑ no O N/A ❑ <br />T <br />than 5 gallons per minute, a pumping test must be performed <br />Pumping Data Received yes O no O N/A O <br />as follows: <br />As built sketch on page 'L G'� <br />A. Pump and related equipment shall be installed and <br />Bacteriological Sample Received yes ❑ no ❑ <br />the static water level measured. <br />Water System Approved yes ❑ no ❑ <br />B. Pumping shall begin at a rate of withdrawal greater <br />Sanitarian Date <br />II. Criteria for approval of well and well yield are as <br />than 5 GPM until water level drops to a point close <br />to bottom of the well. <br />follows: <br />C. At this point, the pump rate shall be adjusted so <br />The well must produce a: <br />the water level remains constant <br />A. Minimum of 1 gallon per minute for 6 continuous <br />D. Measure and record the volume of water discharge <br />and water level (electric tape) at 15 minute intervals <br />pumping hours after the well has been pumped <br />throughout the test <br />out according to Part I, Sec. B of this permit <br />E. Discharge water at least 50 feet from the well and <br />B. The pump test can be terminated early and well <br />sewage disposal area. <br />yield considered adequate if. <br />F. Interruption of pumping longer than 15 minutes <br />1. The well cannot be pumped out as stated in <br />shall require extending the pumping time that <br />Part I B of this permit <br />amount of time. <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 />gl,�ranc(oncsk <br />The well /water system is to be •seastuicted as specified <br />C. Sufficient storage and yield may be considered for <br />by the permit attached plans and specifications ❑. <br />approval. <br />D. Person conducting the pump test shall collect a <br />This water system construction permit is null and void if <br />sample to be analyzed for constituents described <br />(a) conditions are changed from those shown on the <br />in Codified Ordinances of Loudoun County Title <br />application (b) conditions are changed from those shown <br />4, Chapter 1040, Appendix III. <br />on the construction permit <br />E. Replacement wells are exempt from this <br />requirement <br />Date: -%' cl Z60 Issued by: � `–� <br />This Construction <br />inn.^ <br />Date: V3 Reviewed by -' -�- � <br />Permit Valid until <br />° Zq ° rov <br />Original / Health Department Copy / Applicants Copy <br />