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Page Of �- <br />( <br />Well/Water System Construction Permit <br />Loudoun County, Virginia Health Department <br />//0;? WAa 11 <br />Division of Environmental Health identification Number <br />Map Reference � <br />777 -0234 Metro 478 -8408 r OR9@0©MOZE0 ©o <br />General Information <br />�,/ }, f – 1) /} 44 <br />New ❑ Repair ❑ Abandonment L`� Upgrade ❑ Well ID.# Vv Vlfb U � I � � l,� <br />Based on the application for a well /water supply system construction permit filed in accordance with Chapter 1040, Codified <br />Ordinances, a construct on permit is hereby issued to: <br />Owner P "%­ Se._hoc�` elephone 11 \- b`1bo- <br />Address L, Pf. s 0 <br />IFor a well /water system which is to be constructed on /at k5 t c) <br />Subdivision Section /Block a- Lot <br />DESIGN <br />NOTE: INSPECTION RESULTS <br />Water supply, existing: (describe) 74Z <br />Water supply location: Satisfactory yes ❑ no D <br />Drillers Report (G.W.2) Received yes ❑ no ❑ <br />J <br />To be installed: class <br />Cased and Grouted t Bed plus 10' or a minimum <br />cased Gr ed whichever is greater <br />Well Construction Approval yes El no ❑ <br />Sanitarian to <br />Well Location See age <br />Well Driller V ttV <br />Pump Ins I�jc tt <br />I. If well yield as determined by 30 minute airlift test is less <br />Chemica ��thy Da ived yes ❑ no D N/A ❑ <br />than 5 gallons per minute, a pumping test must be performed <br />Pumping ata Receive yes D no ❑ N/A ❑ <br />as follows <br />As built sketch on page <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 />The well /water system is to be constructed as specified <br />C. Sufficient storage and yield may be considered for <br />by the permit D or attached plans and specifications D. <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 />re=irement <br />Date: Issued by: <br />This Construction <br />s+^R > <br />Permit V lid until <br />Date: Reviewed by: _ <br />Original / Heahh Department Copy / Applicants Copy <br />