COMMONWEALTH OF VIRGINIA

Form GW-2 WATER WELL COMPLETION REPORT DEQ WELL # ______

USGS LOCAL # ______

Revised 12/1/00 (Certification of Completion/County Permit)

Virginia Dept. Of Environmental Quality DEQ Permit ______

P.O. Box 10009

Richmond, VA 23240-0009 County Permit ______

Certification of inspecting official:

COUNTY / CITY ______This well does ____ does not ____

(County / City Stamp) Meet code/law requirements.

Signature: ______

Virginia Plane Coordinates Date: ______

______N Owner ______

______E Well Designation or number ______ For Office Use

Latitude & Longitude Address ______

Datum: ______Tax Map I.D. No. ______

______N Subdivision ______

______W Phone ______Section ______

Topo. Map No. ______Block ______

Elevation ______ft. Drilling Contractor ______Lot ______

Formation ______Address ______Class Well I ______IIA ______

Lithology ______IIB ______IIIA ______IIIB ______

River Basin ______Phone ______IIIC ______IIID ______IIIE ______

Province ______

Type Logs ______WELL LOCATION: ______(feet/miles) ______(direction) of ______

Cuttings ______and ______(feet/miles) ______(direction) of ______

Water Analysis ______If possible please include map showing marked well location.

Aquifer Test ______

Date Started ______Date Completed ______Type Rig ______

1. WELL DATA: New ___ Reworked __ Deepened ____ 2. WATER DATA: Water Temperature ______F

Total Depth ______ft. Static Water Level (unpumped level measured) ______ft.

Depth to Bedrock ______ft. Stabilized measured pumping water level ______ft.

Hole Size (Also include reamed zones) Stabilized Yield ______gpm after ______hours

______inches from ______to ______ft. Natural Flow: Yes ____ No ____ Flow Rate ______gpm

______inches from ______to ______ft. Comment on water quality: ______

______inches from ______to ______ft. 3. WATER ZONES: From ______To ______

Casing Size (I.D.) and Material From ______To ______& From ______To ______

______inches from ______to ______ft. From ______To ______& From ______To ______

Material ______4. USE DATA

Weight per ft. ______or wall thickness ______in. Type of Use: Drinking _____ Livestock Watering _____

______inches from ______to ______ft. Irrigation _____ Food Processing _____ Household ____

Material ______Manufacturing _____ Fire Safety _____ Cleaning _____

Weight per ft. ______or wall thickness ______in. Recreation _____ Aesthetic _____ Cooling/Heating ____

______inches from ______to ______ft. Injection _____ Other ______

Weight per ft. ______or wall thickness ______in. Type of Facility: Domestic ____ Public Water Supply ___

Screen Size & Mesh for Each Zone Public Institution ____ Farm ____ Industry ____

______inches from ______to ______ft. Commercial ____ Other ______

Mesh Size ______Type ______5. PUMP DATA: Type ______Rated hp. ______

______inches from ______to ______ft. Intake Depth ______ft. Capacity ______gpm at _____head

Mesh Size ______Type ______6. WELLHEAD: Type of Well Seal ______

______inches from ______to ______ft. Pressure Tank ______gal. Location ______

Mesh Size ______Type ______Sample Tap ______Measurement Port ______

______inches from ______to ______ft. Well Vent ______Pressure Relief Valve ______

Mesh Size ______Type ______Gate valve ______Check Valve (when required) ____

Gravel Pack Electrical Disconnect Switch on Power Supply ______

From______to ______ft. 7. DISINFECTION: Well Disinfected _____ Yes _____ No

From______to ______ft. Date ______Disinfectant Used ______

Grout Amount ______Hours Used ______

From______to ______ft. Type ______8. ABANDONMENT: (where applicable) ____ Yes ____ No

From______to ______ft. Type ______Casing Pulled ____ Yes ____ No ____ NA

Plugging Grout From ____ to ____ Material ______

OWNER: ______DEQ WELL # ______

USGS LOCAL # ______

9.  State law requires submitting to the Virginia State Water Control board information about ground water and wells for every well made in the State intended for water, or any other non-exempt well. This information must be submitted whether the well is completed, on standby, or abandoned. Information required includes: an accurately and completely prepared water well completion report, full data from any aquifer pumping tests, drill cuttings taken at ten foot intervals (unless exemption is secured), the results of any chemical analysis, and copies of the geophysical logs. Quarterly pumpage and use reports are required from owners of public supply and industrial wells. County or State permits to drill may be required in some parts of the state. Some counties require submission of a water well completion report. The Virginia State health Department requires a water well completion report for public water supply.

10.  Driller’s Log (Use additional sheets if necessary) 11. 12. Diagram of Well

Construction

(with dimensions)

Depth (feet) Type of Rock or Soil Remarks Drilling

Time

From To (Color, material, fossils, hardness, etc.) (Water, caving, cavities, (Min.)

broken, core, shot, etc.)

13. Well Lot Dedicated? _____ Size _____ ft. by _____ ft. Well House? ______

Distance to nearest pollutant source ______ft. Type ______

Distance to nearest property line ______ft. Building ______ft.

14. WATER SERVICE PIPE: Checked under ______p.s.i. for ______minutes

Pipe Size ______in. Material ______

Installer ______

Date ______

15. I certify that the information contained herein is true and correct and that this well and/or system has been installed and

constructed in accordance with the requirements for well construction as specified in compliance with appropriate county or

independent city ordinances and the laws and rules of the Commonwealth of Virginia.

Signature ______Date ______

(Well driller or authorized person)

License Number ______