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Home My WebLink AboutWAT2022-00319 - WAT Application - 12/7/2022 WAT 2022. - 031 ll MASON COUNTY 1 . ,i!i ,,,,..:1,-: COMMUNITY SERVICES RECEIVED t; ' Building,Planning,Environmental Health,Community Health IQ"tl.l I".o‘'` DEC Q 7 2022 415 N 6'h 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 615 W. Alder Street 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: ' x y 61r) t v S Date: 1 7—S-- 2_2___ Mailing Address: 29 0 , Roc,;K U tee:.: Fiyone: 360-24s13--CG'›_ (' Parcel Number: Li 20/?-// 9'603 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more An- Building permit —60 2022-D is I' connections) ❑ Division of land: (Eg Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ 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: -1 E3 yn LkYi. ei? ,�S-7-L1A. `� Water Facility Inventory (WFI) Number: 6 n E ( w Cl. 7 001 - 000E 9 J (write"none"for two-party) )(I am the manager of this water system. The water system has been approved for a services. There are presently connection(s) in use. This will be the I connection. 0 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 an limits set,by s nd-io ulation. Signature of Water System Manager Date 12 — / '.,--- — This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Re',scd 1,25,2018 , Individual Water Well Water well report(attached to application). Depth I,Qo O ft. NI:(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://qis.co.mason.wa.us/planninq 14 15rn 16n 22n Water use or limitation recorded N/A Yes ETWell Drilled Date (#(// (0 Individual Spring/Surface Water O WDOE permit(attach to application) O 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) \ Satisfactory Determination: �,L 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). C ,�,Reviewer's Signatures: 1 I Environ. Health: SkC p y y ' Date ` l � 5 1 `01.2 CSD Director: Date + . es. . , , WATER WELL REPORT .. Original&1" cops-Ecology, 2n0copy-owner. i copy- WE06023 IL .1 i 6 t drmer CURRENT i Notice of Intent No. Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. BAC325 0 Construction Decommission ORIGINAL INSTALLATION Water Right Permit No. EXEMPT WELL Notice of Intent Number Property Owner Name BILL.FOX PROPOSED USE: 0 r-- [,� Domestic 0 Industrial ❑Municipal Well Street Address SHEI.TON-HAYCOCK ROAD(DAYTON) DeWater Imgatton 4-.I Test WetO1her - CountyMASON TYPE DF WORK Owner's*umber of well(it mom than one) LOT 2 City SHELTON QNew well 0 Reconditioned Method: El Dug ❑Bored 0 Driven ❑ Deepened ❑Cable l!Rotary 0 Iened Location/5UL 1/4-1/4 NE 1/4 Sec 18 Twn20N R 4W row 0 Check DIMENSIONS:Diameter of well 6 inches.drilled 1 g t R. (s,t,r Still REQUIRED) OrOne Depth of completed wel� O R Lat/Long Lat Deg Lat Min/Sec CONSTRUCTION Ill lWol DETAILS LongDegLong Min/Sec Casing I]Welded 6 " Diem.from +2 ft to 176 ft. hum from ft to ft Installed: ❑Liner installed ft to R. Tax Parcel No.(Required) 420181100030 (LOT 2) Threaded • Dram From Perforations: D Yes ❑x 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 ir..by tn.and no of parts ft nature of the matenal in each stratum penetrated,with at(cast one entry for each change from fl.1O of information (USE ADDITIONAL SHEETS IF NECESSARY.) Screens: Eyes ❑Nn ❑r.K-Pac Location 172 MATERIAL I FROM I TO Manufacturer's Name JOHNSON BROWN SILTY CLAY,GRAVEL 1 C I 5 i Type SLOTTED Model No BROWN SILT,GRAVEL 5 116 Gran: Slot sn< t Dram 5 Slot size.010 b om ft. 175 t.to ft.to 1�0 _ft BROWN SILT BOUND SAND,GRAVEL. . 16 1 31 _ BROWN SILTY SAND,GRAVEL 31 14R GravdlFllterpadted: ❑ Yes ❑x No Stu of gravel/sandGRAY SILT 48 � 76 Materials placed from ftP,.ro GRAY SILT,GRAVEL 48 1 Surface Seal: E Yes ❑ No To what depth") 2.0 ft' BROWN SILT,GRAVEL,WET 76 95 Material used net seal BENTONITE CHIPS GRAY SAND,WET❑ 95 105 GRAY CLAY 105 115 Did any strata contain unusable water? Yes a❑ No 115 1134 type of water? Depth of strata GREEN CLAY,SILTY Method of sealing strata of. _ BROWN FINE MEDIUM SAND•WET 134 1 146 I GRAY SILTY CLAY 146 153 • Type Manufacturer's Name GRAY SILTY SAND,GRAVEL,WET 153 176 Type H P 176 180 BROWN SANDY FINE MEDIUM,WATER ft 1 WATER LEVELS:Land-surface elevation above mean sea level 628/07 Static level Fl(_WING( ft.below top of well Date _r�_ Artesian pressure lbs.per square inch Date (cap.valve,ac) 1 Artesian water is controlled by WELL TESTS:Drawoown is amount water level is lowered below static level Was a pomp test ma m de? ❑ Yes Q No If yes,by who Yield:: gnl.muri.with ft.drawdown efts hrs. Yield gal./min with ft.drawdown after hrs. Yield. gal./min with ft.drawdown after hrs. Recovery data(time taken as zero when pump turned off',(water level measured from well I _ top to water level) Tune ware,Level Time Water Level Time Water Level r-- Date of test — hrs_ I Bailer Test €a' !ruin with ft.drawdown after Airiest gal 'in with stem set at R.for hrs- Artesian flow 20 g_p.m Date 6/28/07 Start Date 6l26I07 Completed Date 6/2R/07 Temperature of water' Was a chemical analysis made 0 Yes Q 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 used and t • formation reported above are true to my hest knowledge Company ARCADIA DRILLING INC. ElDrilleroEngineervTrainee Name(P ) SHU I EPP DrillingAddress PO BOX 1790 Driller/Engineer/Trainee Signa ture 2874 WA 98584 Driller or trainee License No. City.State,Zip SHELTON --4 IF TRAINEE Driller's L aSC No I D NI N 41886 Conutratios Date 6/29/07 Registration No. AKCADD1098K1 Drillers Signature. r Ecology is an Equal OpportunityEmployer ECY 050-1-20(Rev 4/07) Printed From Mason County DMQ Printed from Mason County DMS - I Thurston County Environmental Health i. IdOik. t... 2000 Lakeridge Dr. SW t Olympia, WA 98502 } — - 360 867-2631 L. - t'. THURSTON COUNTY" k szummiimmulas COLIFORM BACTERIA ANALYSIS f' i.. Coun (: Date Sample Collected Time Sample ty Collected y. I �"+� : ,% ❑PM S� j ikk' Monrn Day Year t' Type of Water System(check only one box) Private Ilodseho , --/ is . Other : "�.�4,, L4� I 0 GroupA ❑Group B Y . , I. Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# ' System Name: . Contact Person: �"'�,�; g,.rN, ;. e' '\s. t Day Phone: 1.( ) ,r)— :. 4 Cell Phone:( 1 f ) rr , < , • f•. E-mail:, . 4't°- 'r.- , ,, 3 1 r ne,). ,. ' Send results to:(Print full dame,address and zip�od ddlese or email a ) qLe., ` SAMPLE INFORMATION S�mple collected by(name): ---- , t� i locationr� Specificor address where sample collected_, Special instructions or comments: + `.. . t.a t•Y\Cx 4.1 a(...K...~s, )'mod t:. i , .. Type of Sample(must check only one box of#1 through#4 listed below) ,. 1. } Routine Distribution Sample 2.Repeat Sample(after unsat.routine) o Chlorinated:Yes No ❑ Distribution System -t- t� t Chlorine Residual:Total_Free Chlorinated:Yes No U l• .• 3.Raw Water Source Sample Chlorine Residual.Total Free J 0 E.coti—GWR(NP) Fecal-surface.GIN',springs(numeration) Unsatisfactory routine lab number: . Q. k.f\ t.•• 0 6 ' Filtered:Yes No _ — ❑Assessment Monitoring(NP) Unsatisfactory routine collect date: i ,;.:, DOther 1 t i;. S 4,0 Sample Collected for Information Only p•• Investigative Construction I Repairs Other MIMI LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY.,'. i (' C�4iefnr4nn� t.: rl Unsaticfactnry Tntal r:nlifnrm Pracant and