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PAGE 3 of g <br />' HEALTH DSPARTMBAI'P <br />IDBDiTIIrICATION / _T4018741000~_ <br />' TAZ MAP ~ _90136C <br />OWNBR Rack Springs <br />' DATE 9292004 <br />TEST WELL INSTALLATION REQUIREMENTS <br />1. The Well Contractor must be licensed by the Loudoun County Health Department to install <br />water supply systems. <br />2. This permit is for a test well to meet the hydrogeological study requirements. <br />3. The well maybe utilized as a private individual water welUsupply in the future if all the <br />minimal set back distances listed below are met. <br />HOUSE OR STRUCTURE 50 FEET <br />DRAINFIEI;D AREAS 50 FEET <br />PROPERTY LINES 10 FEET <br />OTHER POLLUTION SOURCES 50 FEET <br />4. If the well is found not to meet the minimum setbacks, the well maybe <br />properly abandoned or other adjustments will be made as required (i.e., <br />dr'ainfield moved, etc.). <br />