HomeMy WebLinkAboutWEL2001-00026 - VAR Application - 6/15/2001 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES -
Environmental Health Water Quality erso ealth
APPLICATION FOR WELL SITE INSPECTION
Receipt# �Dat�-01 Received ByjA _Tidemark#WEAQ
INSTRUCTIONS
I1. Provide a location sketch and a detailed plot plan. The location sketch should be detailed sufficiently so that a field inspector
cej ens°ly find the site. The detailed plot plan shall show the precise location of the we!l,dimensions of the property,the
location of all existing septic systems within 100 ft.of the well,and the location of any structures on the property.
�2. Clearly stake out or flag the well site.
�3 Submit the completed application and fee to the Health Department,POB 1666 Shelton,WA 98584
APPLICANT/PARCEL IDENTIFICATION
WATER SYSTEM NAME
OWNER NAME f o )e �� t`^ TELEPHONE(360 ) "17P _ S 3 60
APPLICANT NAME �s t c-co�0 b'-- TELEPHONE(360 1 971 - S3 97
SITE/WATER SYSTEM ADDRESS !VG sy8 I $ems. C�k O�w`v6 RC
MAILINGADDRESS !YE S`18I 3, ' CSIC Utw,tAo p`�- I - W6
CITY srArE
ASSESSOR'S PARCEL NUMBER A G_ 1 — 13 — 9 a o
SUBDIVISION (IFAPPLICABLE) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE: 7 rn k u-�- ``,� (, /G kC bO,+
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WATER SOURCE IS:_NEW OR_EXISTING; WELL OR _SPRING 7 NUMBER OF PROPOSED CONNECTIONS
H:\WDATA\ARCHIVMWELLSITE.FM3 Update:December 18, 1997
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File txMnal and Oral COPY with Department at Ingy WATER WELL REPORT Application No. ......... :.... .
Tout pyY Drlwar
a Copyy
STATE OF WASMINGTON Permit No. .... ......._............
(1) OWNER:. Name.. . .__9... ._....✓.(nt t 6' ¢'_✓t ......... . .. Address. _........ .
(2) LOCATION OF WELL: county a 5. a t L ..._...... ... .._ . $ . zva/i. Sec. .._ T.Z7.N.. R.Z....-W.M
Beari and distancefrom section or subdi viainu rornri
(S) PROPOSED USE: Domestic 0 In.lustrial tI Mutdeipal❑ (ill) WELL 1.0G:
Irrigation ❑ Test Well I I Other ❑ Yormation: Describe by color•character,size of material and stricture,one
- _— ,Now Ihirioirss of aquifers and the kind and nature of the material is each
stratum penetrated, with at least one entry for each change of formation.
(4) TYPE OF WORK: Owmer5 number of well .__ ., ..._._._,_-._..--- --'-- _
(if more than hod: .. _....____. MATERIAL lROM TO
New well �I Method: lluR ❑ Bored ❑ '- ----'* ' '--'--- ---
Deepened ❑ Cable bd Driven ❑ /
Reconditioned ❑ Rotary❑ Jetted ❑ _
r
5 DIMENSIONS: Diameter of well ----
Drilled....LS.I.... . -ft. Depth of completed well /t$'-„!j itches. r _. _ Ca ✓ _-_
r _
(8) CONSTRUCTION DFy'FAILS: -
Casing installed:. .G........ Diam. from C ft. to NO 1. ft -4�r -7
__ .. ..
1.
r-
Tbreedad❑ " Diam. from _ ft to . - ft. -
Welded❑ ... m•• Diam. train ft. to _ _.... _ ... ft.
Perforations:
Yee❑ No
Type of Perforator used ......__ ...._..._.. ... . ._.. ... r l _ T/•�
SIZE of perforations -- in. by ... . ....... in.
perforations from _.._.. .._... it. to ... ft,
.................. perforations from . . ft. to ..__ .. .. ft. r-
... perforations from ft. to _..... ft. 3..
Screens: Yes ld No❑ J u ti K g -_
Manatecttye 'a Name a'I ....... ' / �lt N c' tf_{srri✓1� ItI _S - -� ���
55- Model No ... _
Type.- ...... /tom. _ . ..
Diam,_3 Slot ■in ! .J from % n. to /J ft. r ( - -- — -- _- -- --
o �/ �f T- �f-- -
Y4r fl` iolam .-.J Slot sill _.. _ from /`/6 11. to /S S It. ! r" t/_ _ . _. _. -._ �:/.
Gravel packed: Yes❑ No g Size of gmvc•i.
Gravel Placed from .......... ..... .. Ic to __ .. ft.
Surface Seal: Yes (Y Rohr TO What depth) II ..' .ft. -- --- -- i - - -
MatMal wed In/seal. . 4 PNt.v�s f' �l (.JGN fCLr lr'•C
-...-
Did any strata contain unusable wale•" .es Q No Ci
Type of water?...... _ ... Depth of >t,ta
Method of sealing strata off.
(7) PU-.IP: Manufacturers Name. - -- - --- ..---r a.
Type: ....... ......
(8) WATER LEVELS: Land-surface eb,alie" -- _ --i _--
( above mean xea le,el
.
Static level ..... ..... V ...._.tt. below top of well Date
Artesian pressure .....Abs.-per square inch Date
P -_
Artesian water is controlled by. - - - ---- -- ----
(Cap, valve. etc
(8) WELL TESTS: Drawdown is amount Water level is lowered below sumc level Wvrk
l0.4
Was a pump test made? Yes ❑ No ❑ If yes, by whom
Yield: gal./min. with ft. drawdown ail, m. WELL DRILL. R'S STATEMENT:
1 'Phis well was drilled under my jurisdiction and this report is
,. .• •• D;Ic to the best of my knowledge and belief.
Recovery data (time taken as zero when pump tur+c<I off) (water level /
measi . rd from well lop to water level)
Time Water Level I Time Witter Lip 1 I I n.,• wnl,•r L,•m,l K.\MI t-:. ... .. : �.�f /. .r.l..l.l/n .. ._ _ ... .. print)
.....
D`ersun, firm, or corpontion)� (Type ol prinq
........... .. ........ .... ........_ ....... _.... ._ ££ ��/( f � //
i ........ Address...�5,�..ti�.` .. e Gh. .P.h/....Jh'k4.Yg
. .... - ... .. �� ...................................
................Date of test ..._. Jam. .' ISihn rij .µ... .
13 lar test.._p / "gal/min with " ( ...ft ttrewdown .+ftei ..�r..lira. /�7`- (Well Driller) -
Artesian flaw ............ .. .. .....g.p.m. Dale
Temperature of water.. .. . Was a chemical analysis made? Yes ❑ No r Liccrt:e Nu.. . ... ...... . Date. .. .( ........ I1/.�.X
I liSk' ADDI.1•II.N.AI. :•Il Kk TS III NECESSAIIYI
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