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County Of Loudoun Division of Environmental Health Leesburg, Virginia 20177 (703) 777 -0234 Metro (703) 478 -8408 Fax (703) 771 -5023 Automated Inspection Request (703) 771 -5331 WELL/WATER Permit # T30179210001 Owner Name: FAIRFAX COUNTY WATER AUTHORITY Owner Name2: /65/////////4B Owner Address: 8570 EXECUTIVE PARK AVE Permit Purp: FAIRFAX VA22031 -2218 Applicant Name: FAIRFAX COUNTY WATER AUTHORITY Applicant Name2 : Well p val yes no Sanitarian Date 8•�5�03 �� Applicant Address: 8570 EXECUTIVE PARK AVE FAIRFAX VA22031 -2218 Permit Active Date: 2003 -12 -19 Pin #: 005208207000 Tax Map #: /65/////////4B Construction Purpose: OTHER Permit Purp: WATER WAB Structure Type: STRUCTURE TYPE Site ID : Well p val yes no Sanitarian Date 8•�5�03 �� Home Phone: Work Phone: Subdivision: ,)." ",� n S e, eC0. -o XQ Lot: i rr Bldg /Floor /Unit: C�UI COQ! — we �� g �C Or^ to t � �� nri7>� }O JLtF41+ r.o� et New ❑ Repair ❑ Abandonment I Upgrade F1 Well ID # _ Based on the application for a well /water supp y system construction permit filed in accordance with Chapter 1040. Codified Ordinances, a construction permit is issued to: FAIRFAX COUNTY WATER AUTHORITY DESIGN NOTE: INSPECTION RESULTS Water supply, existing: (describe) Water supply location: Satisfactory yes --// no El Driller yes no ❑ To be installed: class t �ived ,{� 1Q Cased and Grouted to Bedrock plus 10' or a minimum Well p val yes no Sanitarian Date 8•�5�03 �� cased ' Grouted ' whichever is greater Well Location. See Page Well Driller .Lic # J� Ly Pump Installer Lic # �N/A 1. If well yield as determined by 30 ' ute irlift test is less uality Data Received yes ❑ than 5 gallons per minute, a pumpin es ust be performed pumping Data Receive es no ❑ N/A El as follows: As built sket age B o ogical Sample Received yes ❑ no A. Pump and related equip a bt be installed and the static water level measured. 1� Water System A ved yes ❑ no El B. Pumping shall be i a withdrawal greater than 5 Sanitarian Date GPM until water le 1 ps�a oint close to bottom of the VVVVVV 11. Criteria for approval of well and well yield are as follows: well. The well must produce a: / C. At this point, the ump rate shall be adjusted so the water level remains nstant. A. Minimum of 1 gallon per minute for 6 conti ous D. Measure a record the volume of water discharge and pumping hours after the well has been pu ed out water lev (electric tape) at 15 minute intervals throughout according to Part 1, Sec. B of this p rmit. the to B. The pump test can be terminated r and well yield E. Dis arge water at least 50 feet from the well and sewage considered adequate if: Ow posal area. 1. The well cannot be pum d t a stated in Part 1, F nterruption 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 or greater for 3 hours of continuous u after Part 1, Sec.B of this permit are ted. The well/water is to be constructed as specified by C. Sufficient st and yield may be considered for by the permit approval. D. Person co ucting the pump test shall collect a sample This water system construction permit is null and void if to be alyzed for constituents described in Codified (a) conditions are changed from those shown on the Ordi nces of Loudoun County Title 4, Chapter 1040, application (b) conditions are changed from those shown A endix III. on the construction permit. E. eplacement wells are exempt from this requirement. Date: 2003 -12 -19 Issued By: This Construction /. Permit Valid Until Date: Reviewed By: 2004 -12 -19 4