1 Start 2 Complete Blasting Form / Project Location Information: Note: You must have a valid VA811 blasting ticket before completing this form. Company/Organization Contact Person Phone Number Email Project Location / Parcel ID Number Miss Utility (VA 811) Ticket Number Loudoun Water Project Number (if known) Blasting Plan Do you have a controlled blasting permit from Fire Marshall? Yes No Proposed Blast Date Proposed Blast Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Proposed Blast Date: Day Day12345678910111213141516171819202122232425262728293031 Proposed Blast Date: Year Year20242025202620272028 Proposed Blast Time AM PM Maximum Anticipated Vibration Frequency (Hz) Peak Particle Velocities (in/s) Peak particle velocities and air blast overpressure at nearest structures and utilities reported using scaled distance calculations. Air Blast Overpressure (dB): Requirement is less than 128dB at any LW infrastructure Attach the Following: A sketch showing the locations of the proposed controlled blasts and seismograph unit(s) in relation to Loudoun Water facilities, north arrow, labeled LW infrastructure (size, type), proposed distance of blasting from LW infrastructure, nearest street(s), nearest address or coordinates. (See example) Upload File(s) Upload More Information Upon receipt of the completed blasting form and files, Loudoun Water will review the information and respond within 48 hrs with further requirements (based on critical infrastructure determination) or no further requirements needed. Additional requirements could include: Blast monitoring (minimum one seismograph); submitted results within 48 hours following each blast Leak survey (by contractor) for water/reclaimed linear infrastructure CCTV (by LW) for sanitary linear infrastructure Pre/Post-blast survey for critical, vertical infrastructure I have read and understand that Loudoun Water may have additional requirements for this controlled blasting activity based on the information provided. I agree to work with Loudoun Water to protect the Loudoun Water infrastructure during the blasting event. Responsible Person Name Submit