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Well/Water System Construction Permit Page Of 7 <br />Loudoun County, Virginia y.. Health Department <br />Division of Environmental Health Identification Number ✓ 6 h1 ,4 (3 <br />7� <br />777 -0234 Metro 478 -8408 <br />Map Reference <br />1-oll X V- p #,yu,%f 7---, General Information 9' , <br />New ❑ Repair ❑ Well ID. #O(Q?Qtg -�, 0Y7% — <br />Based on the application for a well /water supply system construction permit filed in accordance with Chapter 1040, Codified <br />Ordinances, a construction Permit is herepy issued to: <br />/t%�, ( , �ya4di'a 1764 00 3 — % �3 <br />Owner Telephone <br />Address V3 7y /-a / /u /CP5 (. f-a—" 7- 2 .0 3 3 <br />For a well/ w ter s .stem which 'is to be constructed 9n Lad <br />Subdivision Section /Block per„' yri (oS Lot <br />DESIGN <br />NOTE: INSPECTION RESULTS <br />Water supply, existing: (describe) eZ 4- t 7-5 <br />Water supply location: Satisfactory yes no ❑ <br />Drillers Report (G.W.2) Received yes ❑ no X <br />balled: class <br />d Grouted to Bedrock plus 10' or a minimum <br />Well Construction Approval yes ❑ no ❑ <br />Grouted whichever is eater <br />Sanitarian Date <br />tion See Page <br />Well D riller L i c # <br />Pump Installer Lic # <br />I. If well yie as determined by 30 minut irlift test is less <br />Chemical Quality Data Received yes El no El N/A El <br />than 5 gallons r minute, a pumping to ust be performed <br />Pumping Data Received yes El no El N/A ❑ <br />as follows: <br />As built sketch on page Z/� <br />A. Pump and relat equip nt shall be installed and <br />Water System Approved yes ❑ no <br />the static water le I asured. <br />Sanitarian Date <br />B. Pumping shall begi t a rate of withdrawal greater <br />1. Criteria for approval of well and well yield are <br />than 5 GPM until ate evel drops to a point close <br />to bottom of th well. <br />foll <br />C. At this poin , the pump ra shall be adjusted so <br />s: <br />The II must produce a: <br />the water vel remains cons nt. <br />D. Meas and record the vol um f water discharge <br />A. Minim of 1 gallon per minute for 6 ntinuous <br />and ater level (electric tape) at 1 minute intervals <br />pumping ours after the well has en pumped <br />t ughout the test. <br />out accordi to Part I, Sec. B of t ' permit. <br />E.. Discharge water at least 50 feet from a well and <br />B. The pump tes can be termina d early and well <br />sewage disposal area. <br />yield considered dequate if: <br />F. Interruption of pumping longer than 15 inutes <br />1. The well canno e p ped out as stated in <br />shall require extending the pumping time that <br />Part I B of this per it <br />amount of time. <br />2. The Well yields 2. or greater for 3 hours <br />of continuous in after Part I B of this <br />is ted. <br />permit com <br />The well /water system is to be Gonstcjcted as specified <br />C. Sufficient stor a and yield may a considered for <br />by the permit W or attached plans and specifications ❑. <br />approval. <br />D. Person nducting the pump test s II collect a <br />This water system construction permit is null and void if <br />sampl to be analyzed for constituents escribed <br />(a) conditions are changed from those shown on the <br />in dified OrdiOrdi <br />Ordinances of Loudoun Cou Title <br />application (b) conditions are changed from those shown <br />4 h apter 1 Appendix III. <br />on the construction permit. <br />E eplacement wells are exempt from t <br />requirement. <br />Date: �L 7 �t Issued by: — <br />This Construction <br />,9 nit rian <br />Permit Va u it <br />Date: l" �l ��� Reviewed by: <br />✓vi San*rian <br />Original / Health Department Copy / Building Department Copy / A�?plicants Copy <br />Ao O e <br />oo; o/ln /w� 5. <br />