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Well/Water System Construction Permit Page __L 01 <br />Loudoun County, Virginia Health Department <br />Division of Environmental Health identlfication Number 14/ 41 I <br />777 -0234 Metro 478 -8408 Map Reference <br />General Information <br />Nelly-E� Repair ❑ Abandonment Upgrade El Well ID.# <br />Based on the application for a well /wat supply system construction permit filed in accordance with Chapter 1040, Codified <br />Ordinances,, a construction permit is hereby issued to: eL : %v w,, <br />Owner C �f�� c.c �% ��f �-' j O n% Telephone, <br />I For, a well /water system which is to be constructed on /at <br />Subdivision <br />Section /Block <br />Lot <br />DESIGN I NOTE: INSPECTION RESULTS <br />Water supply, existing: (describe) <br />To be installed: class <br />Cased and Grouted to Bedrock plus 10' or a minimum <br />cased & 41" Grouted Ti, KC,1 whichever is greater <br />Well Location See Page Y% <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 system is to be constructed as specified <br />by the permit or attached plans and specifications <br />This water system construction permit is null and void N <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 />Date: 10 <br />Date: <br />Issued by: <br />Water supply location: Satisfactory yes no ❑ <br />Drillers Report (G.W.2) Received <br />yes no ❑ <br />Well Construction proval <br />yes 1� no ❑ <br />Sanitan, �-� t� Date 7 <br />Well Driller Lic # <br />Pump Installer <br />Lic 11 <br />Chemical Quality Data Received <br />yes ❑ no ❑ N/A ❑ <br />Pumping Data Received <br />yes ❑ no N/A ❑ <br />As twill sketch on page <br />f l <br />Bacteriological Sample Received <br />yes ❑ no ❑ <br />Water System Approved <br />yes ❑ no ❑ <br />Sanitarian <br />Date <br />11. 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 if <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 111. <br />E. Replacement wells are exempt from this <br />requirement <br />Reviewed by: <br />sup —iwry <br />Original / Health Department Copy'/ Applicants Copy <br />This Construction <br />Permit Wid}!ntil <br />AV 11749 P <br />Q1 <br />