TM _

Form OW- 2 ,

SANDONL-

4r

7

CQMMQNWE6LTH OF VIRGINIA

State Water Control Board
P. O. E3ox 11143
2111 North Hamilton Street
Richmond, Virginia 23230

WATER WELL COMPLETION REPORT

BWCM No.

Certification of Completion /County Permit
SWCB Perm*

County Permit

G 17U

County /city_-

w—

Gertification of inspecting official:
This well doee

does not

meet codellow requirements.

S.

Virginia Piano Crxrrdinates

Date

N

Owner . r t- ! j!' a ag!t24

For Offic9 use

Well Designation or Number

t,atltude R Longitude

iTe-. & r

Address

1'

2

N

Tax Map I. D. No.

w

Phone

Subdivision

DrIlling Contractor: Northern Virginia Drilling, Inc.

Block

Topo. Map No.

Section

Elevation
Formation

Address

Lot

11356 Industrial Road
Manassas. VA 20109
Phone: ( 703) 361 -6859

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

It possible please Include map showing location marked)

Aquifer Test

Date startec! •
WELL DATA: New

Reworked

Date completed

Deepened

WATER DATA • Water Temperature

Total depth

ft,

Depth to bedrock

ft.

Sole size ( Also Include reamed zones)

Stalk: water level ( unpurnped level- measured)

StablGzed measured pumping water level
Stabilized yield

gpm after

inches from _

to

ft,

Natural Flow: Yes

inches from

to

ft,

Comment on quality

inches from

to

ft.

Casting size ( 1. D.) and material
inches from _

to

1G <-0yr- 7,a44—'

Type rig

ft,

Material

No

hours
flow rate:

3. WATER ZONES: From

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

Type of use: Drinking

Livestock Watering
Household
Food processing
Manufacturing
Fre Safety
Cleaning
Recreation
Aesthetic
Cooling or heating
Irrigation

Injection

Other

Type of facility Domestic

Wt per foot

or wall thickness

in.

Screen size and mesh for each zone ( where applicable)
inches from

Mesh size

to

Commercial
ft.

Type

Mesh size

to

ft,

to

ft.

Type
inches from

Mesh size .,..
inches from

Mesh size.

5. PUMP DATA: Type •

Rated W. P.

Capacity

to

ft.

gal. Loc

Sample tap
Well vent

Type

Measurement port

Pressure relief valve

Gate valve

Check valve ( when required)

Electrical disconnect switch on power supply

Gravel Pack

7. DISINFECTION: Well disinfected _

From

to

ft,

From

to

Le

Grout

head

at

S. WELLHEAD: Type well seat

Pressure Tank

Type

Industry

Other

Intake depth •

inches from

Public water supply

Public InsiltutionlFarm

4Amount 22
Date /

Disinfectantt used

Yes

Hours used—,

2!!5f

8. ABANDONMENT (where applicable) + Yes ''~

From _

to

ft., Type

Casing pulled Yes

From

to

ti., Type

Plugging grout From / QD• to Q

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

Fax ( 703) 771 -5023

Inspection Request ( 703) 771 -5808

WELL /WATER Permit # T20361450002
Owner Name:

AMERICAN TEL & TELEGRAPH CO OF

Permit Active Date:

2012 -07 -11

Owner NameZ:

ATTN: J DIFERDINANDO,TAX DIR

Pin #:

477387669000

Owner Address:

PO BOX 7207

Tax Map #:
N307921 -7207

BEDMINSTER

7////////

59/

Construction Purpose:

WELL ABANDONMENT

Applicant Name:

AMERICAN TEL & TELEGRAPH CO OF

Permit Purp:

WATER WAB

Applicant Name2:

ATTN: J DIFERDINANDO, TAX DIR

Structure Type:

STRUCTURE TYPE

Applicant Address: PO BOX 7207

System Type :

BEDMINSTER

Home Phone:

Work Phone:

Subdivision:

Ext
Lot:

12355 White Rock Road, Purcellville, VA - Rt. 7 W to Rt. 9 toward

Directions to property :

Charlestown, R @ Harpers Ferry Rd. R @ White Rock Rd. -

A LOCATIONAL

CLEARANCE IS REQUIRED BY B & D
New _

Abandonment

Repair _

Hydrofrack

Upgrade _

X

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

Water supply, exist' ng: (
ToTo be- i+eleHed:

describe) DRY HOLE

INSPECTION RESULTS

Water supply location:

Satisfactory

Report ( G. W. 2) Received

class

Cased and Grouted to Bedrock plus 10' or a minimum

Well Construction Approval

cased N/ A Grouted N/ A whichever is greater

Sanitarian Sanitarian

Well Location.

5 gallons per minute, a pumping test must be performed

as fo

ws:

A. Pum

NOVA

Well Driller

See Page

If well yield as determined by 30 minute airlift test is less
th

DateDate

yes El

no

yes

no El

yes

no

2-6-13

100' WAB
witness

Lic #
Lic #

Pump Installer

Chemical Quality Data Received

yes

no

NIA

Pumping Data Received

yes

no

N/ A

Bacteriological Sample Received

yes

no

Water System Approved

yes

no

As built sketch on page
nd related equipment shall be installed and the static

water le

I measured.
II begin at a rate of withdrawal greater than 5

B. Pumping s

GPM until wat

level drops to a point close to bottom of the

well.

Sanitarian

11.

Date

Criteria for approval of well and well yield are as follows:

The well must produce a:

C. At this point, the p

p rate shall be adjusted so the water

level remains constant.

D. Measure and

record

A. Minimum

the

olume

water level ( electric tape) at

of water discharge

and

5 minute intervals throughout

the test.

of

1

gallon

per

minute

for

6

continuous

pumping hours after the well has been pumped out
accorc}4tg to Part 1, Sec. B of this permit.
B. The puritp test can be terminated early and well yield

E. Discharge water at least 50 feet

m the well and sewage

disposal area.

considered adequate if:

1.

F. Interruption of pumping longer than 15 m

utes shall require

extending the pumping time that amount of
q

Sec. B of airs permit.

2.

e.

The well+'isannot be pumped out as stated in Part 1,

The well yiel ds
'
2. 5 GPM or greater for 3 hours of

continuous puhiping after Part 1,

ar cs/

The well /water system is to be Ewpctfuct"

as specified by the
permit X and attached plans /specifications. _

Sec. B of this

permit are compl0ted.

C. Sufficient

storage

an

yield

may be considered for

approval.

This water system eerrstrv ctienn permit is null and void if ( a)
conditions are changed from those shown on the application
b)

conditions

are

changed

from

those

shown

on

the

D. Person conducting the pu
to

test shall collect a sample

be analyzed for constitugrtts described in Codified

Ordinances of Loudoun County Title 4, Chapter 1040,

comstruction permit.

Appendix III.

E. Replacement wells are exempt from

Date:

012 -07 -11

Date:

U

Issued By:

is requirement.

This Construction

Permit Valid Until

Reviewed By:

2013 -07 -11

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

State Water Control Board

BWCM No,

WATER WELL COMPLETION REPORT

P.O. Box 11143

2111 North Hamilton Street
Richmond. Virginia 23230

m-=

Certification of Completion /County Permit
I-L,, e i *;<- 3

SWCH PemNt

County Permit

Certification at inspecting official:
This well does

does not

Meet cudalow requirements.
S.

Virginia Plane Coordinates

Date

N

m et-7G'" r4 7e i- 2- 71 CQ,16:12hGo.

Owner _

For Office Use

W811 Designation or Number

Latitude 3 Longitude

Q 315' 5

Address .!
N

LL,,i7 77-?',
Tax Map I. D. No.

W

Phone

Subdivision

Drilling Contractor. Northern Virginia Drilling, Inc.

Block

Topo, Map No.

Section

Elevation
Formation

Address

Lithology
River Basin

i

11356 Industrial Road

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

it possible please include map showing location marked) ++

Aquifer Test

Date started •

1. WELL DATA: New

Reworked—

Date completed

Deepened

Total depth

WATER DATA • Water Temperature. ..
ft

Depth to bedrock

ft

Hole size ( Aiso include reamed zones)
inches from

Static water level ( unpumped level-measured)

Stabilized measured pumping water level
Stabilized yield

to

Natural Flow: Yes

Comment on quality

to

ft,

itches from

to

tt

Casting size (I. D.) and material
to

gpm after

tt,

Inches from _

Inches from ,_,_„•

Type ng L tY7LJ r i1"
' 1 _.

ft

Material

hourshours

No

flow raja:

3. WATER ZONES: From

To

From

To

From

To

From

To

From

To

USE DATA:

Wt. per foot

or wall thickness

Inches from

to

R.

Material

Type of use: Drinking
Livestock Watering
Irrigation
Household
Food processing
Manufacturing

Wt. per foot

or wall thickness

Inches from —

to

in.

Recreation

it

infection

Material
Wt. per toot

or wall thickness

in.

Screen size and mesh for each zone ( where applicable)
inches from _
Mesh size

to

Fire Satety
Aesthetic

Commercial
g,

Type
Inches from —

Mesh size.^,,,,,__

to

ft,

Type

Inches from

Mesh size

h.

5. PUMP DATA: Type -

inches from
Mash sizes _ _ _ _

to

Sample tap
Well vent —

ft.

Type

Industry

Rated H. P.

Capacity -- _. -

Gate valve

gal. Loc

Measurement port

Pressure relief valve

Check valve (when required)

Electrical disconnect switch on power supply

Gravel Pack

7. DISINFECTION: Well disinfected
1? 9 - / Disinfectant used S.
Date /
el"",

From

to

ft,

Frorn

to

ft.

Grout

From

Amount

3I

Hours used

8. ABANDONMENT ( where appricable) • Y •
to
tc

ft.. Type
ft., Type

headhead

at

6. WELLHEAD: Type well seat"
Pressure Tank

Type Y _ .

Public water supply
Farm

Other

Intake depth _••,,,,
to

Cleaning

Cooling or heating

Other

Type or 1aC +llty Domestic
Public institution_

r•,

From

Urn

Casing pulled Yea

No - J—

Yes

NoNo

I•
121E

r No
rot Applicable

i

matenai &
Plugging grout From l00, to- 0—

Z ,

Yq i 7"
OVER

ABANDONED

County
OfLoudoun
Division ofEnvironmental Health

Page 1 of 4

Leesburg, Virginia 20177
Office ( 703) 777 -0234

Fax ( 703) 771 -5023

Inspection Request ( 703) 771 -5808

WELL/WATER Permit # T20371350001
Owner Name:
Owner Name2:

AMERICAN TEL & TELEGRAPH CO OF

Pennit Active Date:

2012 -07 -31

ATTN: J DIFERDINANDO, TAX DIR

Pin #:

477387669000

Owner Address:

PO BOX 7207

Tax Map #:

BEDMINSTER
Applicant Name:

NJ07921 -7207

AMERICAN TEL & TELEGRAPH CO OF

Applicant Name2: ATTN: J DIFERDINANDO, TAX DIR
Applicant Address: PO BOX 7207
BEDMINSTER
Home Phone:

7////////

WELL ABANDONMENT

Permit Purp:

WATER WAB

Structure Type:

STRUCTURE TYPE

System Type
Work Phone:

Subdivision:

Ext
Lot: , /

J 9Yl

dQ 3

H

1770007—

Rt. 7 W to Rt. 9W R on Harpers Ferry Rd. to R on White Rock Road to
the top # 12355 - A LOCATIONAL CLEARANCE IS REQUIRED BY B & D

Directions to property :

New _

59/

Construction Purpose:

Repair _

Abandonment

X

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

WaterWater supply,supply, existing:existing:
(
(

describe)describe)

NOTE:

DRILLEDDRILLED WLWL

INSPECTION RESULTS

Water supply location:

Satisfactory

Drillers Report ( G. W. 2) Received

To be installed: Blass

abandonment

Well Construction Approval

Cased and Grouted to Bedrock plus 10' or a minimum
cased N/ A Grouted N/ A whichever is greater

Sanitarian

Well Location. See Page,

Well Driller

I. , If well yield as determined by 30 minute airlift test is less
thanthan 55 gallonsgallons perper minute,minute, aa pumpingpumping testtest mustmust bebe performedperformed
asas follows:follows:

Date

NOVA

yes

no

yes

no

yes

no

2-6-13

Lic #
Lic #

Pump Installer

Chemical Quality Data Received

yes El

no

pumping Data Received

yes El

no

NIA

El

N/ A El

As built sketch on page
A. Pu

and related equipment shall be installed and the static

waterlevel measured.

B. Pumping shall begin at a rate of withdrawal greater than 5
GPM until water level drops to a point close to bottom of the
well.

Bacteriological Sample Received

yes

no

Water System Approved

yes

no

Sanitarian

Date

II. Criteria for approval of well and well yield are as follows:
The well must produce a:

C. At this point, t4R pump rate shall be adjusted so the water
level remains con tant.
D. Measure and

recor

A. Minimum

the volume

of water discharge and

water level ( electric tape) at 15 minute intervals throughout
the test.

of

pumping

according t

B. The pump tes

E. Discharge water at least 50 feet from the well and sewage
disposal area.

F. Interruption of pumping longer than 15 minutes shall require

minute

well

has

for

6

been

continuous
pumped

out

art 1, Sec. B of this permit.

an be terminated early and well yield
if:

The well cannot be

umped out as stated in Part 1,

The well yields 2. 5 GP
continuous

permit X and attached plans /specifications. _

per

Sec. B of this permit.

2.

The well /water system is to be constructed as specified by the

gallon

considered adequ

1.

extending the pumping time that amount of time.

1

ours after the

pumping

after

r greater for 3 hours of
art

1,

Sec. 6

of

this

permit are completed.

C. Sufficient storage and yield may

a

considered

for

approval.

This water system construction permit is null and void if ( a)
conditions are changed from those shown on the application
b)

conditions

are

changed

from

those

comstruction permit.

shown

on

the

D. Person conducting the pump test shall c

lest a sample

to be analyzed for constituents describe

in Codified

Ordinances of Loudoun County Title 4, Ch

ter 1040,

Appendix III.

E. Replacement wells are exempt from this requirement.

Date:
Date:

2012 -07 -31

6

Issued By:
Reviewed By:

This Construction
Permit Valid Until
2013 -07 -31