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.� e-� T — of Z <br />Well/Water System ,p�/��r Permit Page <br />Loudoun County, Virginia Health Department G <br />Division of Environmental Health Identlfication Number lei / ec"Ag VF <br />777 -0234 Metro 478 -8408 9 <br />Map Reference �LJJ��ff LJL/JUU /U <br />General Information <br />New ❑ Repair ❑ Abandonment Upgrade ❑ Well ID.# <br />Based on the application for a well /water supply system construction permit hied in accordance with Chapter 1040, Codified <br />Ordinances, a con permit is hereby issued to: <br />5f °i �mcS �7d3) t'oS�i- Y000 <br />Owner o Telephone <br />Address ��_ 1 A20 � k 00 �nnA I%• <br />I For a well /wafer system which is to be constructed on /at '-o s k <br />IL4 U�� a D.., <br />Subdivision Section /Block ly5 Loth <br />DESIGN <br />NOTE: INSPECTION RESULTS <br />Water supply, existing: (describe) <br />�f <br />Water supply location: Satisfactory yes rYO ❑ <br />Drillers Report (G.W.2) Received yes IC. no ❑ <br />To be installed: class IV <br />F}sj Da.� �lCn <br />Well B �A_pproval yes 1! no ❑ <br />Cased and Q/rro�uted to Bedrock plus 10' or a minimum <br />Sanitarian "" Date <br />cased _� Grouted whichever is greater <br />Well Location See Page 7i <br />Well Driller Lic 4 <br />Pump Installer Lic 11 <br />1. If well yield as determined by 30 minute airlift to is less <br />Chemical Quality Data Received yes ❑ no ❑ N/A ❑ <br />than 5 gallons per minute, a pumping test must be rformed <br />Pumping Data Received yes ❑ no ❑ N/A ❑ <br />as follows: <br />As built sketch on page <br />A. Pum/pum d related equipment shall installed and <br />Bacteriological Sample Received yes ❑ no ❑ <br />the water level measured. <br />Water System Approved yes ❑ no ❑ <br />B. Pum shall begin at a rate withdrawal greater <br />Sanitarian Date <br />II. Criteria for approval of well and well yield are as <br />than M until water leve rops to a point close <br />to b of the well. <br />follows: <br />C. At tint, the pum rate h I be adjusted so <br />The well must produce a: <br />the level rem ns <br />A. Minimum of 1 gallon per minute for 6 continuous <br />D. Meaand r rd the u e of water discharge <br />and r lev (electric tape) a1 15 minute intervals <br />pumping hours after the well has been pumped <br />throa test <br />out according to Part I, Sec. B of this permit <br />E. Disa water at least 50 feet from the well and <br />B. The pump test can be terminated early and well <br />sewisposal area. <br />yield considered adequate if. <br />F. Inte on 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. or 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: ' Z�"-91� Issued by: This Construction <br />•^ Permit Valid until <br />Date: Reviewed by: � �' 2- <br />Original / Heatth rtment Copy / Applicants Copy <br />