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Home My WebLink AboutWAT2023-00006 - WAT Application - 1/5/2023 (2) • 0064 R tD 415 N.6th Street MASON COUNTY JAN 05 L . 3 Shelton,WA 98584 4.11°-111"1COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 615 VV. Alder S t r elfar :360-275-4467,Ext.400 ,I Building,Planning,Environmental Health.Community Healthac :360-482-5269,Ext.400 Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No determination can be made until Par, 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: Cy►i 1 e pA(Z K AIL Date: I-5 20Z Mailing Address: q 1 5 K14 L t Lll1 biz Phone: NDO.55o • 1000 Parcel Number: 2.i0t6:1- SO01 O Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit 30 2L3'-10 connections) ❑ Division of land: It Individual water source (one connection), #of Parcels? SPL A 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) 0 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. 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 Forms\Drinking Water Revised.1 27 2021 . Individual Water Well Water well report(attached to application). Depth 1 1 ft. Well capacity Test (attached to application) LAO 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://gis.co.mason.wa.us/planning 14�X15 16_22 Water use or limitation recorded N/A /� Yes Well Drilled Date 1,1 1/2.1 I al 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: 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: C` I '7r'1 Date Z� ----e:-3 This form may be scanned nd available for public view at www.co.mason.wa.us. Page 2 of 2 RECEIVED `. WATER WELL REPORT CURRENT JAN 05 273 Original& I"copy-Ecology,2id copy-owner,3td copy-driller Notice of Intent No.WE19636 APiMCNT O{EC ~ 111'. Aide( Street Notice of Intent NumberOLOGY Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No.BI 81 ® Construction Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATiO.N Property Owner Name Gary Schuvten till CMunicipal Address PROPOSED USE: ® Domestic ❑ industrial 0 Well Street f _ Lynch Road 0 DeWater 0 irrigation ❑ Test Well 0 Other City Shelton County Mason TYPE OF WORK: Owner's number of well(if more than one) ir'I well® NewLocation SW I/4-1/4 SW 1/4 Sec 29 l wn 20N R 2W EWM 0 0 Reconditioned Method:0 Dug ❑ Bored ❑ Driven 0 Deepened 0 Cable 0 Rotary ❑ Jetted (s,t,r Still REQUIRED) or DIMENSIONS: Diameter of well 6 inches,drilled119 ft WWMRI C Depth of completed well 117ft. CONSTRUCTION DETAILS Lat/Long Lat Deg 47 Lat Min/Sec 11'18"N C Casing ® Welded 6" Crain from +1.5 ft.to 113 ft Long Deg 122 Long MiniSec 57'41"W installed: 0 Laser installed Diam.from ft to ft. Tax Parcel No.(Required)220293450010 V0 Threaded " Diam.From ft.to ft. E Perforations: 0 Yes 0 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.and no.of pert' from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change `C' Screens: ® Yes ® No 0 K-Pac Location 111 of information. (USE ADDITIONAL SHEETS IF NECESSARY.) -... Manufacturer's Name Johnson MATERIAL. FROM TO ao Brown medium sand,gravel 0 28 Type Stainless Slotted Model No Gray medium sand,gravel with 28 Diann.5"Slot size.016 from 112 ft to 117 ft. silt binder 69 Diem Slot size from 11.to ft. 0 ._ Gray silt.wet ' 69 74 -,s,.. GraveUFilter packed: 0 Yes 0 No Sirs of gayelaand 72 Materials placed front ft to i1. Gray clay 74 75 Gray silty sand 75 91 413 Surface Seal: C4 Yes 0 No To what depth''nil Gray clay 91 93 Material used in seal Bentonite Chips Gray medium sand,some gravel 93 w Did any strata contain unusable water? ❑ Yes ® No and water 110 {,'�� Type of water? Depth of strata Brown medium sand,few gravel 110 1 Method of sealing strata off and water — 119 PUMP: Manufacturer's Name _Type: ILP. - _ WATER LEVELS: Land-surface elevation above mean sea level 222 ft. rtil` Static level 25ft.below top of well Date 11/21/2014 , G Artesian pressure lbs.per square inch Date ---" — eg Artesian water is controlled by (cap,valve,etc.) WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump test n•,adet 0 Yes ® No If yes,by whom? Z Yield: ital.imin.with_tt drawdown after hrs. R E V E I\ sr I) Yield: gal./min.with ft.drawdown after hrs. I s.. Yield. aal.hnin.with R_drawdown after hrs. 13 Recost•rvdata(rimetakenaszzerowhenpumprumedoff)(waterlevelmeasuredfrom — DEC 29Zf=14 well top to teaser level) v Time Water Level Time Water Level Time Water Level WA State Departmont 0 of Ecotut y (SWRO) 0 Date Driest ______ 1.1 t Bailer test gal'min with It.drawdown after hrs. Pt Airiest 4_gal.hnin.with stein set at 10011.for 1 hrs. L Artesian flow_g.p.m Date Start Date 11/21/2014 Completed Date 11/21/2014 cv Temperature of water 49 Was a chemical analysis made? 0 Yes 0 No E t WE'LL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well g. construction standards. Materials used an, •c information reported above are true to my best knowledge and belief. El Driller 0 Engineer 0 Trainee tat (Ain os ocpp Drilling Company Arcadia Drilling Inc. Driller/Engineer/Trainee Signature _ Address Po Box 1790 Driller or trainee License No.287• / J City,State.Zip Shelton , Wa, 98584 Q) IF TRAINEE:Driller's License No: Contractor's gDriller's Signature: Registration No. AR('ADD1098K1 _ Date 11/21201.1_-.____ ECY 050-1-20(Rev 02/10) If you need this document in an alternate format,please call the Water Resources Program at 360-407-68?2. Persons with hearing loss can cull 711 for Washington Relay Service. Persons with a speech elaahrlity can call 877-833-6341. RECEIVED -__ • `WATER � r �n�3 - II MANAGII Av' L'l�' '� LAB OR�A�T/OR IESiric. �_ 1515 tt.Otl 6t,v'F'aE3ii1;'1)UA` 04`^:t .IMPF COLIFORM BACTERIA ANALYSIS FORM . Date Sample Collected Time Sample County Collected // i Qyial, Month Day Year q',•�3 44c C Type of Water System(check only one box) \' ❑Group A El Group B Other P V 1 Group A and Group B ns.6—t Provide from Water Facilities Inventory(WFI): ID# System Name:cp,�V;RA— 10 'SE t,\,\t},m c--. Contact Person: /di /+,.�� Day Phone:(316t�)1,i0 644 Cell Phone:( Email: f! Eve.Phone:( ) S n res Its t:(Print full name,address and zip code) -Y>q 1\-0n 8b L SAMPLE INFORMATION Sample collected by(name): r ['c;(/ Specific location where sample collected: Special instructions or comments: . well i\ eaJ Type of Sample(select only one type of sample from types 1 through 5 below) 1"XRoutine Distribution Sample(AN) 2.❑ Repeat Sample(A/P) Chlorinated:Yes No (from distrbution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total_Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S I I I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (A(P) . 4. Surface or GWI Raw Source Water Sample(Enumeration) I S I ❑E.coli ❑Fecal Filtered Yes No 5.❑Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 111 ❑Unsatisfactory Total Coliform Present and Satisfactory • ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform ;100m1. E.coli /100m1. Fecal Coliform /100m1. HPC /1 ml. 4 Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ D tern eceiv Lab Reference Number (051 Receipt Temp C°: n Method Code: S� f/ V23 I3 . Date Reptried to DaH -^ Lab Use Only: DOH Lab-S(aJampl_e#j1J^j d1�1_ (\ /