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Form OW- 2 ,
SANDONL-
4r
CQMMQNWE6LTH OF VIRGINIA
BWCM No.
County Permit
G 17U
County /city_-
does not
S.
Date
t,atltude R Longitude
iTe-. & r
Address
1'
Phone
Subdivision
Block
Section
Elevation
Formation
Address
Lot
River Basin
f,.lass. Well i
Province
Type logs
WELL LOCATION: (
Cuttln%
and __ _ _.
Water Analysis
feet/miles _.
feetlmiles (
IIA
118
MIA
IIIC
MID __
1118
IIIP_
direction) of
direction) of
Aquifer Test
Date startec!
WELL DATA: New
Reworked
Date completed
Deepened
Total depth
ft,
Depth to bedrock
ft.
gpm after
inches from _
to
ft,
inches from
to
ft,
Comment on quality
inches from
to
ft.
to
1G <-0yr- 7,a44'
Type rig
ft,
Material
No
hours
flow rate:
gpm
To
From
To
From
To
From
To
From
To
USE DATA:
Wt per toot
or wall thickness
inches from
to
In.
ft,
Material
Wt per foot
or wail thickness
inches from
io
in,
ft.
Material
Livestock Watering
Household
Food processing
Manufacturing
Fre Safety
Cleaning
Recreation
Aesthetic
Cooling or heating
Irrigation
Injection
Other
Wt per foot
or wall thickness
in.
Mesh size
to
Commercial
ft.
Type
Mesh size
to
ft,
to
ft.
Type
inches from
Mesh size.
Rated W. P.
Capacity
to
ft.
gal. Loc
Sample tap
Well vent
Type
Measurement port
Gate valve
Gravel Pack
From
to
ft,
From
to
Le
Grout
head
at
Pressure Tank
Type
Industry
Other
Intake depth
inches from
Public InsiltutionlFarm
4Amount 22
Date /
Disinfectantt used
Yes
Hours used,
2!!5f
From _
to
ft., Type
From
to
ti., Type
No `
No
ems- UV o
No
Not Applicable
material j6e-47?9Mr
OVER
r,
Page 1 of 5
County
OfLoudoun
Division of Environmental Health
Leesburg, Virginia 20177
Office ( 703) 777 -0234
Owner NameZ:
Pin #:
477387669000
Owner Address:
PO BOX 7207
Tax Map #:
N307921 -7207
BEDMINSTER
7////////
59/
Construction Purpose:
WELL ABANDONMENT
Applicant Name:
Permit Purp:
WATER WAB
Applicant Name2:
Structure Type:
STRUCTURE TYPE
System Type :
BEDMINSTER
Home Phone:
Work Phone:
Subdivision:
Ext
Lot:
Directions to property :
A LOCATIONAL
Abandonment
Repair _
Hydrofrack
Upgrade _
WWDH-2013-0016
Well ID #
Based on the application for a well /water supply system construction permit filed in accordance with Chapter 1040. Codified
Ordinances, a construction permit is issued to: AMERICAN TEL & TELEGRAPH CO OF
NOTE:
DESIGNDESIGN
INSPECTION RESULTS
Satisfactory
Report ( G. W. 2) Received
class
Sanitarian Sanitarian
Well Location.
as fo
ws:
A. Pum
NOVA
Well Driller
See Page
DateDate
yes El
no
yes
no El
yes
no
2-6-13
100' WAB
witness
Lic #
Lic #
Pump Installer
yes
no
NIA
yes
no
N/ A
yes
no
yes
no
water le
I measured.
II begin at a rate of withdrawal greater than 5
B. Pumping s
well.
Sanitarian
11.
Date
D. Measure and
record
A. Minimum
the
olume
of water discharge
and
the test.
of
gallon
per
minute
for
continuous
disposal area.
1.
2.
e.
ar cs/
as specified by the
permit X and attached plans /specifications. _
Sec. B of this
C. Sufficient
storage
an
yield
approval.
conditions
are
changed
from
those
shown
on
the
comstruction permit.
Appendix III.
Date:
Date:
Issued By:
is requirement.
This Construction
Reviewed By:
tJ
WAB Witness
100' ok
JAH 2-5-13
Form GW -2
1976- 10, ouo
A 5A N D0N "vl E N T
COMMONWEALTH OF VIRGINIA
BWCM No,
m-=
SWCH PemNt
County Permit
does not
Date
m et-7G'" r4 7e i- 2- 71 CQ,16:12hGo.
Owner _
Latitude 3 Longitude
Q 315' 5
Address .!
N
LL,,i7 77-?',
Tax Map I. D. No.
Phone
Subdivision
Block
Section
Elevation
Formation
Address
Lithology
River Basin
Lot
Manassas, VA 20109
Phone: ( 703) 361 -6859
Class Well I
118
Province
IIA
IIIA
VIC
IIIB
ti! D _
111E
Type logs
NELL LOCATION: (
Cuttings
and
Water Analysis
feet/miles
feevmiles (
direction) of
direction) of
Aquifer Test
Date started
Reworked
Date completed
Deepened
Total depth
Depth to bedrock
ft
to
Comment on quality
to
ft,
itches from
to
tt
gpm after
tt,
Inches from _
ft
Material
hourshours
No
flow raja:
To
From
To
From
To
From
To
From
To
USE DATA:
or wall thickness
Inches from
to
R.
Material
or wall thickness
Inches from
to
in.
Recreation
it
infection
Material
Wt. per toot
or wall thickness
in.
to
Fire Satety
Aesthetic
Commercial
g,
Type
Inches from
Mesh size.^,,,,,__
to
ft,
Type
Inches from
Mesh size
h.
inches from
Mash sizes _ _ _ _
to
Sample tap
Well vent
ft.
Type
Industry
Rated H. P.
Capacity -- _. -
Gate valve
gal. Loc
Measurement port
Gravel Pack
From
to
ft,
Frorn
to
ft.
Grout
From
Amount
3I
Hours used
ft.. Type
ft., Type
headhead
at
Type Y _ .
Other
Cleaning
Cooling or heating
Other
r,
From
Urn
No - J
Yes
NoNo
I
121E
r No
rot Applicable
matenai &
Plugging grout From l00, to- 0
Z ,
Yq i 7"
OVER
ABANDONED
County
OfLoudoun
Division ofEnvironmental Health
Page 1 of 4
Pin #:
477387669000
Owner Address:
PO BOX 7207
Tax Map #:
BEDMINSTER
Applicant Name:
NJ07921 -7207
7////////
WELL ABANDONMENT
Permit Purp:
WATER WAB
Structure Type:
STRUCTURE TYPE
System Type
Work Phone:
Subdivision:
Ext
Lot: , /
J 9Yl
dQ 3
1770007
Directions to property :
New _
59/
Construction Purpose:
Repair _
Abandonment
Upgrade _
Hydrofrack
WWDH-2013-0017
Well ID #
Based on the application for a well /water supply system construction permit filed in accordance with Chapter 1040. Codified
Ordinances, a construction permit is issued to: AMERICAN TEL &
TELEGRAPH CO OF
DESIGN
describe)describe)
NOTE:
DRILLEDDRILLED WLWL
INSPECTION RESULTS
Satisfactory
To be installed: Blass
abandonment
Sanitarian
Well Driller
Date
NOVA
yes
no
yes
no
yes
no
2-6-13
Lic #
Lic #
Pump Installer
yes El
no
yes El
no
NIA
El
N/ A El
waterlevel measured.
yes
no
yes
no
Sanitarian
Date
II. Criteria for approval of well and well yield are as follows:
The well must produce a:
recor
A. Minimum
the volume
of
pumping
according t
minute
well
has
for
been
continuous
pumped
out
per
2.
gallon
considered adequ
1.
pumping
after
1,
Sec. 6
of
this
considered
for
approval.
conditions
are
changed
from
those
comstruction permit.
shown
on
the
lest a sample
in Codified
ter 1040,
Appendix III.
Date:
Date:
Issued By:
Reviewed By:
This Construction
Permit Valid Until
2013 -07 -31