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Home My WebLink AboutWAT2023-00006 - WAT Application - 1/5/2023 • ti ® aocaocP f• 415 N.6th Street /? MASON COUNTY JAN 05 T'_; Shelton,WA 98584 i COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 6� J VV. Alder S tBelfai •360-275-4467,Ext.400 Building Planning,Environmental Health,Community Healthgw:360-482-5269,Ext.400 Application for Determination of Water Adequacy Instructions 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: CAZA I e PaQ keJL Date: 7� Mailing Address: d1 St K4 G ld VT 612 Phone: oo•55(o • t OOO Parcel Number: ZZOe.-61— rSOO I 0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit ? td 2.62-3-000ID connections) ❑ Division of land: XIndividual water source (one connection), #of Parcels? SPL J Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other (explain) ❑ Other(explain) ❑ Replacement or Remodel (please indicate name 4 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. El 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Fonns\Drinking Water Revised 4/27/2021 • � M Individual Water Well Water well report (attached to application). Depth 1 I R ft. Well capacity Test (attached to application) L-10 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). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14X15_ 16 22 �/ Water use or limitation recorded N/A /� Yes Well Drilled Date l,' \Zt I I '-'+ Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection O 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 • • Part 3: Mason County Community Services Evaluation (staff use only) 4 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. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). I Reviewer's Signatures: Environ. Health: C' t ' ` Date 17_,1 This form may be scanned nd available for public view at www.co.mason.wa.us. J s, r P RECEIVED WATER WELL REPORT CURRENT JAN 0 5 2023 Original Si I"copy-Ecology,2i0 copy-owner,3tO copy-driller Notice of intent No.WE 19636 +V.if nrvea141011 or ��j ECOLOGY Construction/Decommission ("x"in circle) Unique Ecology ID Tag No.BIGo10 N. 5Alder Street :.,. ,V,a,etor, Z Construction Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATION Notice of Intent Number Property Owner Name Gary Schuvten PROPOSED USE: el Domestic 0 Industrial 0 Municipal Well Street Address_ Lynch Road ' 3 0 DeWater 0 Irrigation Test Well 0 Other City Shelton County Mason TYPE OF WORK: Owner's number of well(if more than one) ® New well 0 Reconditioned Method:0 Dug 0 Bored ❑ Driven Location SW 1/4-1/4 SW I!4 Sec 29 Two 20N R 2W EWM 0 0 Deepened 0 Cable ® Rotary 0 Jetted (s,t,r Still REQUIRED) or DIMENSIONS: Diameter of well 6 inches,drilled119 a. WW1r131 Depth of completed well 117R. CONSTRUCTION DETAILS Lat/Long Lat Deg 47 Lat Min/Sec 11'18"N g Casing 0 Welded 6" Itam from +1.5 R to 113 ii Long Deg 122 Long Min/Sec 57'41"W installed: 0 Liner installed 0 Threaded [)fain.from Dram.From n to R Tax Parcel No.(Required)220293450010 R.to ft Perforations: 0 Yes ❑ No CONSTRUCTION OR DECOMMISSION PROCEDURE Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and SIZE of perfs_in.by_in.mid no.of put: from_fl.to ft. nature of the material in call stratum penetrated,with at least one entry for each change C Screens: el Yes El No EI K-Pac Location 111 of information (USE ADDfrloNAl.SHEETS IF NECESSARY.) Manufacturer's Name Johnson MATERIAL l FROM TO Brown medium sand,gravel ' 0 28 , Type Stainless Slotted Model No Gray medium sand,gravel with 28 Diam 5"Slot size.Q16 from 112 fl to 117 ft. Dian Slot size_�from II.to ft. silt binder 69 Gray silt,wet 69 74 "+.,. Gravel/Filter packed: 0 Yes ® No Size of gavelisand Gray clay 74 75 Materials placed from R.to A. IP Surface Seal: ® Yes 0 No To what depth?L9ft Gray silty sand 75 91 Gray clay 91 93 p Material used in seal Bentonite Chips Gray medium sand,some gravel 93 i�rr� Did any strata contain unusable watery ❑ Yes ® No and water 11 p Tvpc of water? Depth of strata Brown medium sand,few gravel 110 Method of sealing strata off and water 1 g PUMP: Manufacturer's Name 4. Type:_ 1 l P — WATER LEVELS: Land-surface elevation above mean sea level 223 R Static level eft.below top of well Date 11/21/2014 _ Artesian pressure lbs per square inch Date - - Artesian water is aattrollyd by (cap,valve,etc.) ---�--- — -' WELL TESTS: Drawdown is amount water level is lowered below static level - Was a pump test made? 0 Ycs el No If yes,by whom? ____.___-_ Z Yield, gal./min.with_ti drawdown after lus. _ RECEIVED Yield: gat/min.with ft.drawdown after hrs. - 5i! Yield. gal./min.with ft.drawdown after hrs. 43 Rerore ty data(time taken as zero when pump turned 0,(1)(water level measured from - well top to water lerzl) U.EC 292014 Time Water Level Time Water Level Time Water Level WA State Department 0 of Ecology (SWRO) Date oftest -- ‘11.1 Bailer test gal./min.with ft.drawdown rifler_hrs. 15 Airtest 4�al/tom.with stem set at 10011.for l hrs. Artesian flow g.p.m Date Start Date 11/21/2014 Completed Date 11/21/2014 W Temperature of water 49 Was a chemical analysis made? 0 Yes ® No E WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well fp construction standards. Materials used • re information reported above are true to my best knowledge and belief O. El Driller 0 Engineer 0 Trainee .• , (Phn os oePP — Drilling Company Arcadia Drilling Inc. ( �,t Driller/Engineer/Trainee Signature i� Address Po Box 1790 Driller or trainee License No.287 City,State,•Lip Shelton • Wa, 98584 ty IF TRAINEE:Driller's License No:' Contractor's Driller's Signature: _Registration No. ARCADDIO98Kt ...— Date I U2,L014.___ EC Y 050-1-20(Rev 02/10) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss con call 711 for Washington Relay.Service Persons with a speech disability can call 877-833-6341. RECEIVED • `WATER na- r'^1 MANAG154EtAT ANL LABORATORIES INC. MOM EO 1515 th.fit I>iTaEot>a;11v/k ib4Qac t mum NW' COLIFORM BACTERIA ANALYSIS FORM - Date Sample Collected Time Sample County Collected // Z7I � q'130 � �5o(1 Month Day Year Type of Water System(check only one box) ❑Group A ❑Group B Other V I Group A and Group B stems Provide from Water Facilities Inventory MR): ID# l��ll /�\ System Name: .�1 � ) , lil Yy1 Contact Person: C` / j Day Phone: 60),v 3 ,b</r Cell Phone: ) Email: Y� Eve.Phone:( Sin t res Its to:(Print full name,address and zip code) 1. p 1 ram✓ P1., SY)q.,1\-0n A SAMPLE INFORMATION Sample collected by(name): • d/ Specific location where sample collected: Special instructions or comments: we IN 1 Type of Sample(select only one type of sample from types 1 through 5 below) 1`/KRoutine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP) Chlorinated:Yes No (from distribution system after unsat.routine) Unsatisfactory routine lab number: Chlorine Residual:Total Free - 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S I 1 Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) IS I ❑E.coli ❑Fecal Filtered Yes_—No 5.❑Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 4 ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform I100m1. E.coli I100m1. Fecal Coliform I100m1. HPC I1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ `DateTi� ervG�; Lab Reference Number 's V Receipt Temp C°: n Method Code: � Date Rep�ried to D2H Lab Use Orly: DOH Lab-S(aample#� 089 a a�j -1 1�(l)(_0 ! _