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Home My WebLink AboutWAT Application - 3/23/2021 ' � rr,t,t. Pq(CiLaKeAkit 1 .077MASON COUNTY . .; COMMUNITY SERVICES %y Building, Environmental Health Community Health ^E CEI'it /M\ 415 N 6th Street, Bldg 8, Shelton WA 98584, ED Shelton: (360)427-9670 ext 400 •:• Belfair:(360)275-4467 ext 400 Elma:(360)482-5269 ext 400 FAX(360)427-7787 'VS Application for Determination of Water Adequacy 6/5 �R 231021 v v• A/der Streot 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. ENVIRQN M NTAL Part 1: Applicant/ Parcel Identification HEALTH Name on Applicant: ' 2-.r.T U i G,LE2 Date: Mailing Address: 16311 N NO2 I-. Sko-z 6Z1-(, Phone: r 25313 .83 Parcel Number: 3-2-1-7- 05 b 0 2-t109 breei t6>'ys.9 tv‘e:t, cow. /yia./ ,',11v to '- iC/r 0(6 i-6 Ai- c.Jes),, 0,,;. 04„, w4 q8`/c.E Type of Water System Reason for Application ❑ Public/Community Water System (2 or more jg. Building permit connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL ,f4 Well fr. O<<t tQ6- /aRq ❑ Boundary line adjustment 0 Spring/surface wateT 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.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth l ` ft. 99 Well capacity Test(attached to application) /6.7 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_ 15 16 22 Water use or limitation recorded N/A Yes Well Drilled Date 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) L. 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. Li 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: `Q�rt Date 2 of2 CSD Director: Date NICHOLSON DRILLING INC. PUMP TEST NAME: Brent Bigler DATE March 8,2021 SITE: 16311 NE North Shore RD TIME Belfair,WA 98528 WELL DEPTH 142 Feet WELL DIAMETER 6 inches PUMP MAKE Jacuzzi PUMP MODEL TANK MAKE TANK MODEL Time Depth Draw Rate Time Depth Draw Rate' Time Depth Draw Rate n.00M, To Down gpm to Down gpm to Down gpm Water Water Water Static 84.4 0.0 40 98.3 13.9 16.7 660 0.0 1 92.1 7.7 45 98.3 13.9 720 0.0 2 95.3 10.9 16.7 50 98.3 13.9 16.7 780 0.0 v 3 96.9 12.5 60 98.4 14.0 840 0.0 4 97.7 13.3 70 0.0 900 0.0 5 98.1 13.7 16.7 80 0.0 960 0.0 - 6 98.3 13.9 90 0.0 1020 0.0 7 98.4 14.0 100 0.0 1080 0.0 8 98.4 14.0 16.7 120 0.0 1140 0.0 9 98.4 14.0 150 0.0 1200 0.0 10 98.4 14.0 180 0.0 1260 0.0 11 98.4 14.0 210 0.0 1320 0.0 12 98.4 14.0 240 0.0 1380 0.0 13 98.4 14.0 270 0.0 1440 0.0 14 98.4 14.0 16.7 300 0.0 1500 0.0 15 98.4 14.0 360 0.0 1560 0.0 20 98.3 13.9 420 0.0 1620 0.0 25 98.4 14.0 480 0.0 1680 0.0 30 98.3 13.9 540 0.0 1740 0.0 35 98.3 13.9 16.7 600 0.0 1800 0.0 RECOVERY, Time Depth Draw Time Depth Draw Time Depth Draw to Down to Down to Down Water Water Water 1 90.9 6.5 11 0.0 45 0.0 2 88.1 3.7 12 0.0 50 0.0 3 86.6 2.2 13 0.0 60 0.0 4 85.9 1.5 14 0.0 70 0.0 5 84.4 0.0 15 0.0 80 0.0 6 0.0 20 0.0 90 0.0 7 0.0 25 0.0 100 0.0 8 0.0 30 0.0 120 0.0 9 0.0 35 0.0 150 0.0 10 0.0 40 0.0 180 0.0 SIGNED BY: Alan Myette-Pump Supervisor 1786SE Mile Hill Drive SPECTRA Laboratories-Kitsap Port Orchard,WA 98366 _When* ke.ra�, www.epectra-lab.com (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Waded Time Sample County 3 / 8 / 2 tl Collected Mama Day Yam --z+—• Y ilAat7b 1 Type of Water System(check only one box) ❑Group A ❑Group 8 ( Other Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFl) tDp -Be • System Name: molt N ( or Moral RO �?GAPA:r C°ntactPeeson: NICHOLSON DRI LING Day Phone: (360)876-4421 Cell Phone: f.rnail Eve.Phone: Send rates b:(PiW tun name•address and alp and or e-mail) .._.....__ BRIT"fNYiLVICHQ S_ ONDRI �.INGr�G.NAILCQM.,_,.. ' ITIC��2TLLING G L.CC SAMPLE INFORMATION Sample consoled by(name): .( ay S dfic location where Pe sample collected: Special Insirtrdlons arconmanls: KO% MO Type of Sample(check only one box) 1.❑ Routine Distribution Semple 2.Repeal Sample(after unsal.routine) Chlorinated:Yes No[] °Distribution System Chlorine Reslduab Total Free_ Unsatisfactory routine tab number: 3.Source Ground Water Rute Sample •_ __ IS I I I Unsatisfactory roullne collect date: ( I ! Triggered Chlorinated:Yes U No U ❑Assessment Ghiorine Restduat Total Free 1. Enumeration So ce Water Sample I l S I I E.co! Fecal-aort a.Gtin so zidwea Yes❑ wo❑ teas Conaclad fa tntormatton On —7 LA8 USE ONLY DRINKING WATER RESULTS USE ONLY 13 Unsatls factory Total Conform Present and Satisfactory ECoilotesenl Ci Ewe absem Replacement Sample Required: Sample too old(>30 hours) 0 TNTC 0 Bacterial Density Re suits:Total ColUorm /100m1 E.cod 1100ml. Fecal Califon 1100mmb. HPC 11 ml. Lab lD Number eoekma• ILL Q ""' VR9 Z021 1�7/2 cJ D mane Coder Date and Time Incubated: SM 9223 B . MAR 0 9 2021 Da'MAR tadMA R 1 0 2021 Data Reported: MAP 1 0 2021 DOH lab-Semptel Lab the Only: 225 . .. �/- 0 oournoh7Nlat bar mod ebrakriooYr/weMr.Kerrla0oaaaar flaws'co III nio W oe+e PNlorr+re faleOi /dapeoNM�iry.sr4