Black Oak Ridge II APPENDIX A WELL PERMITS

County Of Loudoun Page 1 of Division of Environmental Health o`er ' 1•' I Leesburg, {Virginia 20177 `� +` it—. Office(703) 777-0234 Fax(703) 771--5023 ' . ' 'X Inspection Request (703) 771-5808 ,' WELL/WATER Permit # T40322700002 1?$7 Owner Name: ROUSE, RANDOLPH D TRUSTEE Permit Active Date: 2014-05-15 Owner Name2: RANDOLPH ROUSE TRUST Pin#: 588296833000 Owner Address: 6407 WILSON BLVD Tax Map ft: /43//////1/31/ ARLINGTON VA 22205-1506 ,Purpose: NEW CONSTRUCTIO.i; Y Applicant Name: ROUSE, RANDOLPH D TRUSTEE Permit Purp: WATER FTW Applicant Name2: C/O ROBERT COHEN Structure Type: STRUCTURE TYPE Applicant Address:45610 WOODLAND RD; STE 400 System Type IIIB STERLING,VA 20171 Home Phone: Work Phone: I:\t Suhdivision: Lot / Directions to property : Rt. 7 to Round Hill turn R on Rt. 7 Bus.W on E. Loudoun St.turn L /"`'"� 4../:. 7/ 2/ onto Rt. 719- New Cut Road,go 3.5 miles on Rt.719 turn L onto Rt. / 734 0.7 miles. turn L on Rt. 735 0.4 miles. Slight left 0.2 m lets �r,.-L t 1- �2, New X Repair _ Abandonment _ Upgrade _ Hydrofrack Well ID# // Based on the application for a well/water supply system construction permit filed in accordance with Chapter 1040. Codified Ordinances,a construction permit is issued to: RI it Si:.RAs.1101 NI u l RI Is 1 I i DESIGN NOTE: INSPECTION RESULTS Water supply,existing: (describe) DR I I LED WL Water supply location: Satisfactory yes ❑ no ❑ -- To be installed: class IIIB Drillers Report(G.W.2) Received yes ❑ no ❑ Cased and Grouted to Bedrock plus 10'or a minimum Well Construction Approval yes ❑ no cased 55'Grouted 55'whichever is greater Sanitarian Date Well Location. See Page., /- Well Driller Lic# Pump Installer Lic# I. If well yield as determined by 30 minute airlift test is less Chemical Quality Data Received yes Li no LI N/A❑ than 5 gallons per minute,a pumping test must be performed Pumping Data Received yes❑ no ❑ N/A❑ as follows: As built sketch on page • A. Pump and related equipment shall be installed and the static Bacteriological Sample Received yes ❑ no ❑ water level measured. Water System Approved yes ❑ no ❑ • B. Pumping shall begin at a rate of withdrawal greater than 5 Sanitarian Date .,.� GPM until water level drops to a point close to bottom of the II. Criteria for approval of well and well yield are as follows: well. The well must produce a: C. At this point, the pump rate shall be adjusted so the water i level remains constant. A. Minimum of 1 gallon per minute for 6 continuous D. Measure and record the volume of water discharge and pumping hours after the well has been pumped out water level (electric tape) at 15 minute intervals throughout according to Part 1, Sec. B of this permit. the test. B. The pump test can be terminated early and well yield E. Discharge water at least 50 feet from the well and sewage considered adequate if: disposal area. 1. The well cannot be pumped out as stated in Part 1, F. Interruption of pumping longer than 15 minutes shall require Sec. B of this permit. extending the pumping time that amount of time. 2. The well yields 2.5 GPM or greater for 3 hours of continuous pumping after Part 1, Sec.B of this The well/water system is to be constructed as specified by the permit are completed. permit X and attached plans/specifications._ C. Sufficient storage and yield may be considered for approval. This water system construction permit is null and void if (a) D. Person conducting the pump test shall collect a sample conditions are changed from those shown on the application to be analyzed for constituents described in Codified (b) conditions are changed from those shown on the Ordinances of Loudoun County Title 4, Chapter 1040, comstruction permit. Appendix III. E. Replacement wells are exempt from this requirement. fr r,� Date: 014-05-15 Issued By: ___„____ LI ( �GA✓F- This Construction // Permit Valid Until Date: ( Reviewed By: .r' L •'/7 2015-05-15