HomeMy WebLinkAboutWAT2022-00334 - WAT Application - 12/20/2022 dimmonemimin
WATdaa- bb 3-6L1-
�, MASON COUNTY
4� = COMMUNITY SERVICES
- Building.Planning,E nvironmental Health,Community Health
415 N 6th Street,Bldg 8,Shelton WA 98584, r'('�
Shelton:(360)427-9670 ext 400 O Belfair.(360)275-4467 ext 400 O Elms:(360)482 I v L--V
FAX(360)427-7787
Application for Determination of Water Adequacy SEC 2 0 2022
Instructions 615 W. Alder Street
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application,with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Jacob & Kaitlin Geist Date: 12/17/2022
Mailing Address: 51 E Heatherwood CT Shelton, Phone: (360)463-0110
Parcel Number: 52025-21-00020
Type of Water System Reason for Applicationlin 2
❑ Public/ pC El Water System (2 or more Building permit ZJL.'O ,Q�,p2,-6156 ,J
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water
❑ Other(explain) 0 Other(explain)
0 Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable—no
to this well, check the Public./Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ I am the manager of this water system.The water system has been approved for services.
There are presently connection(s)in use.This will be the connection.
❑ 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 line 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 limits set by state and local regulation.
Signature of Water System Manager Date 12/17/2022
This form may be scanned and available for public view at www.co.mason.wa.us.
J:1EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
El Water well report(attached to application). Depth 220 ft.
0 Well capacity Test(attached to application) 2 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.
El Satisfactory bacteriological test(attach to application).
1
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://ais.co.mason.wa.us/planning 14=15Q 16=22LJ
Water use or limitation recorded N/A MI Yes 0
Well Drilled Date 02/21/1994
Individual Spring/Surface Water
I
❑ 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
i
• •
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
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.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
U Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: R-AQ•ii`1\7\lc Date
\ { (-Z:5
1 CSD Director. Date 2 of 2
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pEC2 2 HEALTH
SR
�15 W Alder �� w A T E WELL
wASHINGION P O R T UWniqueRWellWellNI D. St A3t20 8551
L.
O (1) OWNER: Name CBAPNAM, IRIAN Address N 8271 BBII,TD1-11113LOCK RD SEILTOM, WA 91554-
0.
CU
e (2) LOCATION OF WELL: County MASON - 11W 1/4 11 1/4 Sec 25 T 2011 N., R 5N WM
12a) STREET ADDRESS OF WELL (or nearest address) 2431 BIGBLAMD ROAD, MILTON
= 13) PROPOSED USE: DgRBTIC (10) WELL LOG
H (4) TYPE OF WORK: Owner's Number of well Formation: Describe by color, character, size of material
t (If more than one) 1 and structure, and show thickness of aquifers and the kind
ya 1(1W WILL Method: ROTARY and nature of the material in each stratum penetrated, with
at least one entry for each change in formation.
O (S) DIMENSIONS: Diameter of well 6 inches
Drilled 220 ft. Depth of completed well 220 ft. MATERIAL FROM TO
0 ERO CLAY I. GRAVII. 0 6
73 IBf(6) CONSTRUCTION DETAILS: BROWN SAND RAID PAM 6 12
R Casing installed: 6 • Dia. from +2 ft. to 103 ft. GRAY BARD PAN 12 15
E NELDID • Dia. from ft. to ft. BRONX BARD PAN 15 25
" Dia. from ft. to ft. GRAY CLAY 25 27
O MRS BARD PAN 27 30
Ill
Perforations: MO BARD C10IITZD GRAVEL 30 43
C Type of perforator used =R01B1 BAND BARD PAN 43 6/
CO SIZE of perforations in. by in. CITta BLACK PRA GRAVEL 68 74
te perforations from ft. to ft. RAID GRAY CLAY 74 95
a.+
perforations from ft. to ft. BARD GRAY CLAY i GRAVEL 95 101
O perforations from ft. to ft. RAID BLACK BASALT 101 172
0 801T BLACK BASALT 172 179
-0 Screens: NO BLACK BASALT 179 192
DU Manufacturer's Neme SOFT FRACTOIIKD BASALT 192 213
Type Model No. BLACK BASALT 213 220
03
Diam. slot size from ft. to ft.
03 Diem. slot size from ft. to ft.
CI
CO Gravel packed: 110 Size of gravel
t Gravel placed from ft. to ft.
as
>1 Surface seal: YES To what depth? 20 ft.
d.+ Material used in seal IZNTOMITZ
03 Did any strata contain unusable water? MO
L Type of water? Depth of strata ft.
A"'R Method of sealing strata off
(7) PUMP: Manufacturer's Name
Type H.P.
Z (8) WATER LEVELS: Land-surface elevation
(4, above mean sea level ... ft.
40 Static level 152 ft. below top of well Date 02/21/P4
O Artesian Pressure lbs. per square inch Date
TI Artesian water controlled by 1
work started 02/17/94 Completed 02/21/94
O (9) WELL TESTS: Drawdown is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION:
static level. I constructed and/or accept responsibility for con-
() a pump test made? NO If yes, by whom? struction of this well, and its compliance with all
W Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used
end the information reported above are true to my best
y.. knowledge and belief.
Recovery data
c Time Water Level Time Water Level Time water Level NAME ARCADIA DRILLING INC.
d (Person, firm, or corporation) (Type or print)
tADDRESS SR 170 101I.KKR RD
03 Date of test / /
Q Bailer test gal/sun. ft. drawdown after hrs. (SIGNF.D) License No. 2053
0 Air test 2 gal/min. w/ stem set at 215 ft. for 1 hrs.
Q Artesian flow g.p.m. Date Contractor's
Temperature of water Was a chemical analysis made? 3110 Registration No. ARCADDIO9611 Date 02/22/94
CO
I-
ItVO
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap r ` e r6 Twelve Trees Ln NW Ste.C
...Where experience InattersRELI L.. v Poulsbo,WA 98370
Ph
79-5141
ENVIRONMENTAL 111 ��` DEC 20 201Z www.spec'a abcom
HEALTH 615 w. Alder Street
Spectra Labs-Kitsap,LLC (Poulsbo)received samples for Coolwater Drilling on Wednesday,May 11,
2022 at 9:44 am.Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures.A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
217628-01 !Caitlin Geist 2431 W Highland Rd 05/10✓2022 16:15
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
05/16/2022 Page 1 of 1
26276 Twelve
Trees Ln NW A
ste.c 11, SPECTRA Laboratories - Kitsap
___
Poulsbo,WA —Whew experience mantra
98370
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tine Sample County
Collected
®r �/� �LZ y it ❑A&1 04fi
b* Day Yew Ms,9
Type of Water System(check only one bar)
❑Group A ❑Group B gather
Group A and Group B Systems-Provide from Water Fealties Inventory(WFI):
ID#
System Name: !1A.27�l 6L,J'c7
Contact Person: �c`w 4-tfit
Day Phone 3c• 8I a- Fear Cell Phone
Email: Eve.Phone:
Send resets to:(Prat full nalta,aims and alp coda n.mf alone for.Iedlork copy of rasatlej
co et.wi- 4darcs.art( ihrpomte t.
SAMPLE INFORMATION
Sample collected by(dame): ewe C
Specific location where sample collected: Special instructions or comments:
L'J/ tul- 1-12CI1LA -Q 2�
Type of Sample(check only one box)
1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(AM)
Chlorinated:Yes ❑ No❑ (from drstritlbon system after uruat routine)
routine lab number:
Chlorine Residual Total Free Urtsatisfaclory
3.Ground Water Rule Source Sample
Unsatisfm tury routine collect date:
SI
Chlorinated:Yes No
• ❑Triggered(NP) Chlorine Residual:Total Free
❑Assessment(A/P) —
4.Surface or GWI Raw Source Water Sample(Enumeration) I S I I
❑ E.coi ❑Fecal Fired Yes Ib
5.rSxlple Colected for Information Only
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coi present ❑E.coi absent
Bacterial Density Results-Total Coliform mpn/100mi.E.coi mpN100m1.
Fecal Coliform cful100m1. HPC cfu/1ml.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
Lab Reference Number1
Receipt Temp C': Method Code:
Skt92238/QTCOtiPR/SM9222D
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