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Well /Water System Construction Permit Page / Of <br />Loudoun County, Virginia Health Department - <br />Division of Environmental Health Identification Number <br />777 -0234 Metro 478 -8408 <br />Map Reference <br />I 144/' -/,iJ1;� ✓VYl.ti i�General Information /�,� /��" 1 <br />i <br />New Repair ❑ a'4-13 0A -b U"�7 if s Well ID. # ()! <br />Based on the application for a well /water supply system construction permit filed in accordance witFi Chapter 1040, Codified <br />Ordinance cogs ru lion pe mi } s h reby issued to: <br />Owner C q 0 Telephone �C 3 ��` <br />Address Q- �� �� .i E� c!5 k°� f 4 c- a ' o � <br />For a well /wat system which is to be con ruo4ed on /at L ' ''`s <br />JO T i'3 1,.� 7 G Ok", con /p ri ?- 9 . l -)' " t"-'b ,x i <br />Subdivision Section /Block <br />i+ %„ r 3 DESIGN <br />Water supply, existing: (describe) <br />1 �rin-y" F-1, `T I <br />To be instal class <br />Cased and Grouted to Bedrock plus 10' or a minimum <br />cased Grouted whichever is greater <br />Well Location See Page <br />I. If well yield as determined by 30 minute airlift test is less <br />than 5 gallons per minute, a pumping test must be performed <br />as follows: <br />A. Pump and related equipment shall be installed and <br />the static water level measured. <br />B. Pumping shall begin at a rate of withdrawal greater <br />than 5 GPM until water level drops to a point close <br />to bottom of the well. <br />C. At this point, the pump rate shall be adjusted so <br />the water level remains constant. <br />D. Measure and record the volume of water discharge <br />and water level electric tape) at 15 minute intervals <br />throughout the test. <br />E. Discharge water at least 50 feet from the well and <br />sewage disposal area. <br />F. Interruption of pumping longer than 15 minutes <br />shall require extending the pumping time that <br />amount of time. <br />The well /water sys m is to be comsWdeted as specified <br />by the permit 2'or attached plans and specifications ❑. <br />This water system construction permit is null and void if <br />(a) conditions are changed from those shown on the <br />application (b) conditions are changed from those shown <br />on the construction permit. <br />Date: .10110 .1 -11 Issued by: <br />Date: <br />Reviewed by: <br />Lot <br />NOTE: INSPECTION RESULTS <br />Water supply location: Satisfactory yes ❑ no ❑ <br />Drillers Report (G.W.21 Received yes � ❑ <br />Well G�on�Cd pfoval yes no ❑ <br />Sanitarian Date l� _� <br />Well Driller < <Lic # <br />Pump Installer _ Lic # <br />Chemical Quality Data Received yes ❑ no ❑ N/A d <br />Pumping Data Received yes ❑ no ❑ N/A ❑ <br />As built sketch on page <br />Water System Approved yes ❑ no ❑ <br />Sanitarian Date <br />II. Criteria for approval of well and well yield are as <br />follows: <br />The well must produce a: <br />A. Minimum of 1 gallon per minute for 6 continuous <br />pumping hours after the well has been pumped <br />out according to Part I, Sec. B of this permit. <br />B. The pump test can be terminated early and well <br />yield considered adequate if: <br />1. The well cannot be pumped out as stated in <br />Part I B of this permit. <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 />C. Sufficient storage and yield may be considered for <br />approval. <br />D. Person conducting the pump test shall collect a <br />sample to be analyzed for constituents described <br />in Codified Ordinances of Loudoun County Title <br />4, Chapter 1040, Appendix III. <br />E. Replacement wells are exempt from this <br />requirement. <br />4. <br />Supervisory Sanitarian <br />Original / Health Department Copy ! Building Department Copy Applicants Copy <br />This Construction <br />Permit Vali until <br />��J > <br />4 <br />