HomeMy WebLinkAboutWAT2022-00326 - WAT Application - 11/1/2022 W'AT 202,L-06' 2-(e
MASON COUNTY .
t COMMUNITY SERV
ICES
\'',; Budding Planning Environmental Health,Community Healtn
415 N V'Street. Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 :• Elma: (360)482-5269 ext 400
FAX(360)427-7787
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: , J l i Cj-- Date: I t "cA--b-j
ZZ
Mailing Address: L MAIM �) Phone: (2fS) tIl 1 —• .t._,
Parcel Number: 24i)?IA cou 1 -
Type of Water System Reason for Application •
❑ Public/Community Water System (2 or more I"( Building permit bI G) 2V Z - Q F-53 O
connections) 0 Division of land:
tIt Individual water source (one connection), #of Parcels? SPL
. Well 0 Boundary line adjustment
0 Spring/surface water 0 Other (explain)
❑ 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 _
This form may be scanned and available for public view at www.co.masorhwa.us.
Forms',fhmling \atcr Revised 11252018
Individual Water Well
gWater well report (attached to application). Depth ft.
❑ 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).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://ois.co.mason.wa.us/plannui 14{1 151-1 16=22I
Water use or limitation recorded N/A = Yes El
Well Drilled Date
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
•
•
•
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.
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
• reason(s).
Reviewer's Signatures:
Environ. Health: Date
CSD Director: Date 2"'
• WATER WELL R E PORT Start Card No. W12577
• STATE OF WASHINGTON Water Right Permit No. AAD097
e
(1)-OWNER: Name BARTRO, BOB Address 1 2231 1a8O16-BDNSON ROAD GRAPKVIEN, WA 98546-
(2) LOCATION OF WELL: County MASON - NE 1/4 NW 1/4 Sec 3 T 21M N., R 2W WM
(2a) STREET ADDRESS OF WELL (or nearest address) E 2231 MASON-BENSON ROAD
(3) PROPOSED USE: DOMESTIC (10) WELL LOG
(4) TYPE OF WORK: Owner's Number of well Formation: Describe by color, character, size of material
(If more than one) 1 and structure, and show thickness of aquifers and the kind
NEW WELL Method: ROTARY and nature of the material in each stratum penetrated, with
at least one entry for each change in formation.
(5) DIMENSIONS: Diameter of well 6 inches
Drilled 96 ft. Depth of completed well 96 ft. MATERIAL FROM TO
BROWN HARD PAN 0 41
(6) CONSTRUCTION DETAILS: GRAY HARD PAN 41 44
Casing installed: 6 " Dia. from .1.5 ft. to 96 ft. BROWN HARD PAN 44 52
WELDED " Dia. from ft. to ft. BROWN SAND & GRAVEL 52 64
" Dia. from ft. to ft. BROWN HARD PAN 64 66
BROWN SAND PEA GRAVEL 66 74
Perforations: NO BROWN HARD PAN 74 76
Type of perforator used BROWN SAND GRAVEL & WATER 76 95
SIZE of perforations in. by in. SAND & GRAVEL GRAVEL & WATER 95 96
perforations from ft. to ft.
perforations from ft. to ft.
perforations from ft. to ft.
Screens: YES
Manufacturer's Name WESCO
Type SLOTTED Model No.
Diam. 5 slot size .014 from 96 ft. to $8 ft.
Diam. slot size from ft. to ft.
Gravel packed: NO Size of gravel
Gravel placed from ft. to ft.
Surface seal: YES To what depth? 20 ft.
Material used in seal BENTONITE
Did any strata contain unusable water? NO
Type of water? Depth of strata ft.
Method of sealing strata off
(7) PUMP: Manufacturer's Name
Type H.P.
(8) WATER LEVELS: Land-surface elevation
above mean sea level .. . ft.
Static level 31 ft. below top of well Date 09/14/93
Artesian Pressure lbs. per square inch Date
Artesian water controlled by
Work started 09/14/93 Completed 09/14/93
(9) WELL TESTS: Drawdown is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION:
static level. I constructed and/or accept responsibility for con-
Was a pump test made? NO If yes, by whom? struction of this well, and its compliance with all
Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used
and the information reported above are true to my best
knowledge and belief.
Recovery data
Time Water Level Time Water Level Time Water Level NAME ARCADIA DRILLING INC.
(Person, firm, or corporation) (Type or print)
ADDRESS SE 17 P
Date of test / / 1.
Bailer test gal/min. ft. drawdown after hrs. (SIGNED) l/Z icense No. 2053
Air test 22 gal/min. w/ stem set at 76 ft. for 1 hrs.
Artesian flow g.p.m. Date Contractor's
Temperature of water Was a chemical analysis made? NO Registration No. ARCADDIO9ST1 Date 09/15/93
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