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HomeMy WebLinkAboutWPO201800060 Correspondence 2016-08-19Form GW-2 COMMONWEALTH OF VIRGINIA Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT Page 1 of 4 *Indicates required field or section **Indicates required field or section, if applicable 1. Cnntact lnfnrmatinn* DEQ Well # USGS Local # VDH HDIN # 101-15-0532 VDH PWSID # Contact: Name Address Phone Owner Albemarle County 401 Mcintire Rd Room 420, Charlottesville VA 22902 Driller Wilson Well Drilling P.O. Box 729, Ruckesville Va 22968 434-990-2010 System Provider 2. Well Location* Physical Address: 6659 Mint Springs Park Coun /Ci : Albemarle Subdivision Name: Section: Block: Lot: Tax Ma /GPIN #: 55-28 Latitude: N Longitude: W Datum Source Horizontal: ❑ WGS84 ❑ NAD83 ❑ NAD27 Lat/Long Source Check One): ❑ Map ❑ GPS ❑ PPDGPS ❑ Survey ❑ Imagery ❑ WAAS Location Information Collected B Physical Location Description: Type of Facility (Check One): Type of Use Check All That Apply): 0 Private 0 Drinking/Domestic Use ❑ Agricultural ❑ Food Processing ❑ Waterworks ❑ Manufacturing ❑ Irrigation ❑ Injection ❑ Observation/Monitoring Well ❑ Geothermal (Cooling/Heating) ❑ Fire Safety ❑ Closed ❑ Open: ❑ Returned to Surface O Returned to Aquifer 4. Well Construction* Well designation, Name or Number: Date Started: 6/29/20 1 Date Completed: 6/29/20 Type Rig: Rotary Class Well (Check One): ❑ I ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB 0 RIC ❑ HID ❑ IiIE ❑ IV Construction Type Check One): 0 New ❑ Existing -Modified: o wdl ❑Pump: Date Well De the 500 ft. Total Hole (borehole)Depth: 500 ft. De th to Bedrock: ft. Hole Size (Include reamed zones): 10 inches from 0 to 500 ft. Inches from to ft. Height of Casing above Land Surface: ft.24 inches Casing Size I.D. and Materials:(below) Total Depth of Casing: 28 ft. inches from to ft. 0 infilled, Material Weight per ft. or wall thickness in. inches from to ft. o infiued Material Weight per ft. or wall thickness inu inches from to ft. ❑ infilled Material Weight per ft. or wall thickness in. Screen Size & Mesh: inches from to ft. O infilled Mesh Size Type inches from to ft. O infilled Mesh Size Type inches from to ft. 0 infilled Mesh Size Type Water Zones: from 160 to 162 ft. from 445 to 447 ft. from to ft. Gravel Pack: Size: Type: from to ft. Size: T e: I from to R. Grout Type: 0 Bmtonite Slurry ❑ Neat Cement 0 Bentonite pellets/chips ❑ Concrete O Neat Cement (6% bentonite) from 1) t0 O ft. Grouting Method: Poured from surface Poured through tremmie pipe r Pumped from bottom u ward Type of Seal: 0 pitless adapter ❑ sanitary seal from to ft. Camera Survey: ❑ Yes ❑ No I Date Conducted: Additional Well Construction Form Information Attached: ❑ Yes 0 No Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well # Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local # Page 2 of 4 VDH HDIN # VDH PWSID # Well designation, Name or Number*: 5. Disinfection Well Disinfected: ❑ Yes ❑ No I Date—2. 6. Abandonment (*When abandoning the well. Sections 1 thru 4 must be completed and/or attach orieinal GW-2) Date Started: I Date Completed: Static Water Level (un um ed level measured): ft. Casing Size (I.D.) and Materials: I Casing Pulled: ❑ Yes ❑ No ❑ Uncased Well Depth of Fill: Type and Source of Fill: Grout: From to Type: From to Type: Method of permanently marking location: 7. Pump Test** Static Water Level fun um ed level measured): 10 ft. Date: Method Check One): ❑ Water Tape ❑ Airline ❑ Transducer ❑ Other Stabilized measured pum in water level: ft. Date: Method (Check One): ❑ To of Well ❑ TopofCasing ❑ Surface Level Test Pump Intake Depth: ft I Stabilized Yield: gpin after hours Natural Flow: ❑ Yes ❑ No Flow Rate 2 gpm Estimated Well Yield: gpM 8. Pump Data** Type: ❑ submersible ❑ Turbine ❑ Shallow Jet ❑ Deep Jet ❑ Other: Motor HP: Production Pump Intake Depth: ft I Rated Capacity: m at ft TDH Comments: Formation Lithology Province Geologic Map Used Elevation For Office Use Form GW-2 COMMONWEALTH OF VIRGINIA Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT Page 3 of 4 *Indicates required field or section **Indicates required field or section, if applicable 10. Driller's Log (Use additional sheets if necessary)* DEQ Well # USGS Local # VDH HDIN # VDH PWSID # Well designation, Name or Number: Depth (feet) Type of Rock or Soil Remarks Drilling Diagram of Well Construction (with Time dimensions) Min. From To (Color, material, fossils, hardness, ere.) (Water, caving, cavities etc. 0 10 Red Dirt/ Boulders 10 20 Soft Sandstone 20 500 Blue Rock / Water 11. Certification, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true, accurate, and complete. I am aware tly (here ai# significant penalties for submitting false information including the possibility offine nm and impriso�lft fyr jl( ing v#atiWgf Signature*: J Date:6/30/20 License Number: 2719000751 Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well # Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local # Page 4 of 4 VDH HDIN # _ VDH PWSID # *Indicates required field or section **Indicates required field or section, if applicable Additional Well Construction Data (Use and submit only if additional space is needed) 12. Additional Well Construction Data Well designation, Name or Number: Physical Location: Date Started: Date Completed: Hole Size Include reamed zones): inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. Casing Size .D. and Materials: inches from to ft. o mfined Material Weight per ft. or wall thickness in. inches from to ft. O infilled Material Weight per ft. or wall thickness in. inches from to ft. o infixed Material Weight per ft. or wall thickness in. inches from to ft. 0 infilled Material Weight per ft. or wall thickness in. inches from to ft. o infilled Material Weight per ft. or wall thickness in. inches from to ft. o infilled Material Weight per ft. or wall thickness in. inches from to ft. o iafiued Material Weizht ver ft. or wall thickness in. inches from to ft. O infilled Material Weight per ft. or wall thickness in. inches from to ft. 0 infilled Material Weight per ft. or wall thickness in. inches from to ft. o mined Material Weight per ft. or wall thickness in. inches from to ft. 0 infixed Material Weight per ft. or wall thickness in. Screen Size & Mesh: inches from to ft. o infixed Mesh Size Type inches from to ft. o infilled Mesh Size Type inches from to ft. 0 infilled Mesh Size Type inches from to ft. O infined Mesh Size Type inches from to ft. o infixed Mesh Size Type inches from to ft. 0 infilled Mesh Size Type inches from to ft. 0 infixed Mesh Size Type inches from to ft. 0 infilled Mesh Size Type inches from to ft. O infilled Mesh Size Type inches from to ft. 0 infixed Mesh Size Type inches from to ft. o infilled Mesh Size Type Water Zones: From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to & From to ft. From to ft. From to ft. From to ft. Gravel Pack: Size: T e: From to ft. Size: Type: From to ft. Size T e: From to ft. Size: Type: From to ft. Size: Type: From to ft. Size: Type: From to ft. Grout Type: ❑ Bentonite Slurry 0 Neat Cement 0 Brntonite pellets/chips 0 Concrete ❑ Neat Cement 6% bentonite from to ft. Grouting Method: 0 Poured from surface ❑ Poured through tremmie pipe 0 Pumped from bottom upward from to ft. from to ft.