HomeMy WebLinkAboutWAT2020-00107 - WAT Application - 3/1/2020 • 7 CAN COQ
VI
ENRON EN "' RECEIVED
. ALTHubli MAY 26 2020
fora safer healthier Mason County
415 N 6"'Street,Bldg 8,Shelton WA 98584, 615 W. Alder Street
Shelton:(360)427-9670 ext 400 + Belfsir.(360)275-4467 ext 400 O Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
instructions iT2D2'C0 i 07
Ii. CIW1a " jinade until Part I
12. to the type of water system
I3 Submit IIi$ne to the heaIthd8t review.
Part 1: Applicant/ Parcel Identification
Name on Applicant: 3 0.r 0 o c 31 C r tJ t(d Date: 3 ' I - dL o 5-a
Mailing Address: P'8 X 1101 Qor1 Or ct,0avd 91 hone:: 3 (,o 4 n ; L 9 3 3-
Parcel Number.: 3 a.a.3 5 15 - loll ).
Type of Water System Reason for Application
JAI Public/Community Water System(2 or more % Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
O Replacement(please Indicate name of water
if you have more than one residence connected system below if applicable—no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System: 'ro l?
Water Facility Inventory(WFI)Number: NOfJ
(write`none"for two-party)
I am the manager of this water system.The water system has been ae d for_ .. services.
There are presently I connection(s)in use.This will be the '_connection.
O I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(i.e.: recreational to full time). Please indicate on the following fine the nature
of this change:
This water system is able and willing to provide water to this,(these)connection(s)without exceeding
the limits of the water system or any mits set by stat and local regulation.
^'t
n
Signature of Water System Manager Y Date I
J:\EH Forms\Drinking Water Revised 12/1/15
Page 1 of 2
This form may be scanned and available for public view on the Mason County Web site.
I
Individual Water Well
Water well report(attached to application). Depth 3 14 ft.
O Well capacity Test(attached to application) gpm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results
from these tests are noted on the water well report. Results from these tests will be accepted.
If the water well report cannot be located by the applicant or if the water well report does not
have a capacity test,a well capacity test,which provides stabilization of draw-down and
recovery data,must be performed by a licensed contractor.
{ Satisfactory bacteriological test(attach to application).
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day;and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
Departmental Use Only: Do not write below this line.
Part 3: Mason CountyY Y
Public Health'Evaluation Applicant's water supply does aear adequate to meet the needs of its intended use.
This determination does not address adequacy of the distribution system guarantee
an adequate supply of water indefinitely In the future,or guarantee compliance with all
applicable WDOE water resource regulationS.
(J UnsetEbMy Determination:
S 3Applicant's atar supply does not appear adequate to meet the"needs of its intendeduse for the follàwing reason(s).
4 K tt
rtq :s �4
J:\EH Forms\Drinking Wee Revised 12/1/15
Page 2 of 2
This form may be scanned and available for public view on the Mason County Web site.
1 b I �
WATER WELL REPORT ECE,VEo
% urn►nu w, OrW@W&10copy—ECekpv2"a"-uwners3i eW—driller CURRENT
I c B i o c r Notice of Intent No.
Construction/Deeommission("x"in circle) 2 ( �2�
r ® Construction J Unique Ecology Well ID Tag No.BAB 71
O Decommission ORIGINAL INSTALLATION Water Right Permit No.NA W' A1d err S.--
Notice o Intent Number
3 PROPOSED USE: ® Domestic ❑ ttdestrial ❑ Mmicipat Property Owner Name KEW DEkiYt!E
O DeWeler ❑ langetto. ❑ Tee Well ❑ dyer Well Street Address1300 E TINEER TIC
TYPE OF WORK: Oweer's nasaber of wan(if sose tkao one) City UNION County MASON
® New well ❑ Reconditioned Afth d:❑ Dug 1?Bored ❑Driven
= ❑ Deepened O cable N Rotary O Jested Location MI/4-1/4 , I/4 Sec V Two 22 R 9 W EWM O
DIMENSIONS: Diameter ofwep I motes'drilled. 14 R (a,t,r Still REQUIRED) N` i lrl c i ^
of edwroii 1r EN A,
CONSTRUCTION DETAILS
Coming ® Welded " Diam.from +1 ft.to $ft. Lit/Long Lat Deg Lat Min/Sec ►Lri'H
Installed: ❑ Liner installed_�__" Diam.from__s.to __ft. Long Deg Long Min/Sec
O Threaded _" Diam.From--ft.to _ft. Tax Parcel No.(Required) 3223 5759 0173
PerforatMs: Yes No
= Type of perforator used CONSTRUCTION OR DECOMMISSION PROCEDURE
SIZE of perfs__in.by__in.and no.of perfa^^hour R.to R. F�ab°n' by color'°Mager,size of material and atructrse,and the kind and
screens: 0 Yes ❑ No i K-Pnc Location 337.68 oatn f of the ms t vial in__atratam psaetm/ed,with st leant doe--.7 for each dMmw
of Warmetion. (USE Apgrnoti Sl$IEtS IF ESSARY. _ _ _
lsriufaWuror's IJarrw JNSN MATERIAL FROM TO
Type WELD Model No.TELSC PIPE STICK UP 0 1
Dien.A-Slot sme,,ZQ from 9 e.to 24A ft. BROWN SAND,GRAVEL,CLAY 1 25
3 Diem. Sint size ftem ft.to R BROWN SAND,GRAVEL,CLAY,WET 25 34
Gravewaear packed: ❑ Yea ® No Size of gravel and BRCMN SAND,GRAVEL CLAY 34 52
Materials placed from ft.to ft. BROWN SAND,GRAVEL,SILT, 52
S Surface Sal: N Yes O No To what depth?jilt. SOME CLAY,MOIST 252
Material used in and BENTONITE BROWN SAND,GRAVEL.,CLAY,WET 252 317
Did any carats contain mumble water? ❑ Yes N No BROWNSAND,GRAVEL 317 319
Type of water? Depth of strata
BROWN SAND,GRAVEL.,CLAY 319 336
S Method of sealing strata off B SAND,GRAVEL,WATER 336 344
PUMP: Manufacturer's Name
Type: H.P.
WATER LEVELS: Land-surface elevation above mean pea level fl.
Stow level &.below top of well Date 0812512006
Artesian pressure lbs.per square inch late
Artesian water is controlled by (cap,valve,etc.)
WELL TESTS: Drawdwvn is amount water level is lowered below static level
Was a pump tad made?O Yes 0 No If yea,by wham?
Yield:_gaUmin.with_,_Jt.dtawdown after hrs.
Yield:__gaUnda with R.drawdown after fin.
Yield_jaUmin y ib R dmrdown after tea.
Rraoaoydarn(tune la sn as zero who.pomp turned of(water level meow edfiimn well
kip to wafer level)
jTime Water Level Time Water Level Time Water Level
Date of teat
Bailer test r3 gal./min.with§,ft drawdown after jjns.
Aimed__ aUmin.with stein ant at ft.for bur. StaitDateO8i2lt2008 Completed Date 08/2512008
• Artesian flow_&p.m. Date
Temperature ofwaMr Was a chemical analysis made? O Yes ® No
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
construction standards. Materials nscd and the information reported above arc true to my best knowledge and belief.
Driller O Enncer O Ttaue Ijime(Jim)NiCOLAS SAMPLE Drilling Company NICHOLSON DRILLING INC
Driller /r Address PO BOX 123
Driller ortraineds Lids No.2770' City,State,Zip PORT ORCHARD , WA, 98366
lP TRAINEE:Drifter's License No: Contractor's
Driller's Si Registration No. NICHOD11370M Date 09/1712008
1786 SE Mile Hill Drive
SISC'I7t£ Labaatoriae Port Orchard,WA 98366
-
www.spectra-lab.com
Nrn..i►n+.... .wa )x-7845
COUFORM BACIERIA ANALYSIS FORM
t)e�e Sample Colected The StisipU
1 i fl ! 3-o c ps
o� ,�
TypeofVkWS .m(dtiedcanNan.teic)
a A oarw,►B
GroupAand Group B$yiM1ls—Pmilds ScmWaMrAcliSes kMnlary(WF0
- ;: -sydemN t3C�c
Cacde�.t Penon:'
GelPharce '
6 :: Ey9.Phone
sine».oltlec�rY�ttuhrm..aod�eesand� .;
Sseple 000eded by(nuns): ..
S fb Conform Distribution System
vunk" I S�Imptiag Procedure
S1ng Ose Step Four
1.O Ra e*oitptbusoi sdi b 2 carob(eaer uned.wutlne) Awlidpooar samepiesitee�as 1'hee�e my� to
Yes ❑ No❑ p DlM�bidon System axieeibsootg,lotettdeoldai� powder is the
Ohbdne Reeiduek Tall_ Froe_ ► (with unglslK'er), yor rwove chlorine.Do sot rinse it
thiee8sbcoryrcuthielsbnuntec
out.
3.Sam Ground Wooer Rub Ssn p o ,free
gI 1 1 L / ouuieouIectdde: iosebndhucetabeIowornear To wee
' 1 taking tie smnpii hold tie bottle
OTC t3Clorirebd Yet No Shp Two neathitehudead
❑Aueeraent Gdodne Reddud:Tate_fens Ranove has the hold the top of tha cep with the
t EMM dm sauce Wdw8 npb , 6 , . e Now w thscap.
1.=1_ .. 'loaesead>Iratelbra.If
OE.cal 13Feod-araor awt mmml Y,.❑ ,gyp l J yowe}loeliete DOROTsdth8��pp��DNB,t uch
. apeao,ecedarr�ra�ewenoar site prior to sample collection,be asypartoftheeattlrttl des*e
sersto8t lthoiongkly botdeorleturtl tnttr�ttberi n
aldrit. aftLebottleormaidethemp j
Step Si
8oldtlebottlegsdrtlsstraem of
water,becarefalsettolottlebottle
• toucithessaplotep.Pthebotfl.
toile #ll re,do*otal ow
• it SD Ali.Ranove the bottle
{ Step pnfhasdsrethe
Three
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letitnmithaatystrsnmfor Coiplotedalabs lr.Noteanytbing
ffibsR�emiantios.Befars unsaslt�tibostthesanplo ,
watsrd, intoathin,trosand Stup Eight
lettie iotrtsee Seairethelthaliptoth.botthwjth
3f a is ddorinstad, rwbberbasd.D►ebwrtiuemploto
niessointiefreorhlorisoandiot. Centne&ulythal
Labs
thernessurementDON POfY►TY.��111
eldith8btbsP. possible.
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