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HomeMy WebLinkAboutWAT2023-00052 - WAT Application - 3/6/2023 WAT 2QZ - DD0h-Z- 7 RECEIVED 415 N.6'h Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES MAR 0 6 2023 Shelton:lfair:360-275-4467,Ext.400 \ / Etiildin; annng,Environmental Community Planning,Envital Health,City Health Elma:360-482-5269,Ext.400 615 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: a 4., Ate- Date: 2O2 1 Mailing Address: /3 r2,2 4t,..c S, -t-AA,At aPhone: Zoe - 3q Parcel Number: '224 i 3 - 3/ pL-3 0 y 6 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more $ Building permit IC(202 3-e'jZS connections) ❑ Division of land: X Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ 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: 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. 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. .1-Ill I Forms' Drinking Water Revised 4/27/2021 Individual Water Well 0 Water well report (attached to application). Depth ft. O Well capacity Test (attached to application) Zp 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 1$ 15 16 22 Water use or limitation recorded N/A x Yes11Wk Well Drilled Date / Individual SpringlSurface 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: \ 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: .-N.I\Q-1(Y\ Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 °Depar ,io Copy with WATER WELL REPORT Notice of Intent WE07870 G• second CopyOwners COPY 5.5 UNIQUE WELL I.D.* APQ556 fr Third Copy-Drillers copy 3 2� STATE OF WASHINGTON Water Right Permit No. N1A 1_ (1)OWNER: Name DAVIDMCMULLEN Address 1352234_TH.AVE_&T_UKWILA.WA_9816.8 (2)LOCATION OF WELL: County MASON _sbl 1/4 [ 1/4 Sec -1 T. 21 N.,R W.M. (2a)STREET ADDRESS OF WELL(or nearest address) i40 E RUBY LN__ fn TAX PARCEL NO. 2211330000_— Z.1 (3)PROPOSED USE: 0 Domestic L Industrial HI Municipal (10)WELL LOG or DECOMMISSIONING PROCEDURE DESCRIPTION: C ❑Irrigation []Test Well L;Other Form/aim Describe by color.character.size of material and structure.and the kmd and O I Dawdler nature of the matenal in each stratum penetrated,Wien al Meat one entry fa aadt change of infatuation. Indicate all water encountered C (4)TYPE OF WORK: Owes number of well(It more than one) TO O New Well Method. MATERIAL FROM r LIDeepened ❑Dug ❑Bored BROWN CLAY —___-- 0 12 R ❑Reconditioned ❑Cable ❑Driven GREY CLAY -, 12 31 E Ll Decommission [XI Rotary ❑.Jetted GREY CLAY SEAMS OF SILTS 31 90 4 4O (5)DIMENSIONS: Diameter of well SIX ink WOOD PEAT AND SILTS 90 112 C Drilled 203_., feet. Depth of completed well 203 ,GREY CLAY 112 134 _ n ,GCEMENTED GRAVEL AND SAND 134 154 0/ (6)CONSTRUCTION DETAILS: GREY SAND AND GRAVEL CEMENTED 154 190 r Casing Installed: BROWN SAND AND-CLAY 190 195 [x]Wetded " Diam.from +1.5 ft to_An ft_A BROWN SAND WATER BEARING 195 i 203 8 Li Liner installed " Diam.from ft to ft l 1Threaded " Diam.from _ ftb ft C Perforations: ❑Yes (XR,No CU Type of perforator used ... tQ SIZE of perforations in.by in tQ perforations from ft.to ft Q perforations from ft to ft y _ perforations from ft to ft —__-- t i 4'"a Screens: UYes ❑No ©K-PacLocation 198 >4 Manufacturers Name JOHIISON .-- C Type STAINLESS_STEEL__ -__ model No- TEL '=' R Diem. 6 Slot size 16 from 198 rt.to 203 ft tH-o -s __ • i Diem. Slot size from ft to ft �� �- All R �—tril Gravel/Filter packed: [ iVes LINO Li Size of gravel/sand ris Material placed from — -- ft.to ft. OZD o Surface seal: (XJYee F No To what depth? 18 -_..- ft )a'0� ...aZ Material used in seal BENTONITE r't'i_... -CD r<�1 fA Did any strata contain unusable water? ['Yes !Xi No in IIM l O Type of water? Depth of strata _.c CO Method of sealing strata off - 1 >4 (7)PUMP: Manufacturer's Name C) Type: H.P. — — O • (8)WATER LEVELS: a Land-surface ea level ft - Work Started 112/2008 .19. Completed 1/5/2008---- .19 - W Static level -_j45 _ ft below top of well Dare ,.- WELL CONSTRUCTION CERTIFICATION: N• Artesian pressure Itrs per square inch Oats -_.-__ I constructed and/or accept responsibility for constriction of this well,and its O Artesian water is controlled by _ compliance with all Washington well construction standards. Materials used }a - (Cap,valve,etc) and the information reported above are true to my best knowledge and belief. C d (9)WELL TESTS:Dnewdown is amount water level is lowered below static level Type or Print Name NICHOLAS.J.ERNS T_ License No. 2147 EWas a pump test made? i Yes JS'l No If yes,by whom? (l.irshnsed Dnller/Enquheer) Yield: gal./min.with ft.drawdown after hrs. -- Trainee Name License No. Q Yield: gal/min with ft drawdown alter firs. -- -- - O Yield: gal./min.with ft.drawdown after - hrs. Dolling Company ILLI O._- - CI Recovery data(time taken as zero when pump turned off)(water level measured _ O from well top to water lever) (Signed) — - license No 2147 Time Water Level Time Water Level Time Water Level ( licensed nOTwier) I-" Address PO BOX 2227_BELFAIRWA.98526_._. — — Contractors Registration No. TOPDODCO54RA _ Date 1/22/2008-- ,19 —. Date of test - — Bailer test 20 gal./min.wth 23 ft drawdown after 1 hrs. (USE ADDITIONAL SHEETS IF NECESSARY) Airtest gal./min.with stem set at ft for hrs. Ecology is an Equal Opportunity and Affirmative Action employer. For Artesian flow g.p.m. Date 1/5/2008 special accommodation needs,contact the Water Resources Program at Temperature of water Was a chemical analyses made? Fives LA No (360)407-6600. The TDD number is(360)407-6006. Thurston County Environmental Health Jipz 2000 Lakeridge Dr.SW 4 Olympia,WA 98502 ='�_ " 360 867-2631 T1HURSTON COUNTY inourwormaruswa COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected g' / 2bai CAM i/vA Month Day Year !� :J a 0 PM Type of Water System(check only one box) ❑ Private Household ❑Group A ❑Group B 0the n. le. iudr Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: tot f/LI 9/14.£ 4('V\ Day Phone:(2C) '3 R 6/y d Z Cell Phone:(24:54)"05/6. E-mail: t A tic s( t / MSu ( Eve.Phone:( Send results to:(Print full name,address and zip code or email address) i�4�td 0,4044,41.¢v /3c2' -3 qtt- /4 Sa SAMPLE INFORMATION Sample collected by(name)' vU.C-wt"11.0 t^ Specific location or address where sample collected: Special instructions or comments: • • v-c,eV/eWI1 4 Type of Sample(must cheek only one box of#1 through#4 listed below) 1.'Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free_ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free_ ❑E.coli—GWR(AP) ❑Fecal—Surface,owl,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑Other _ 1 S 4.0 Sample Collected for Information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and tisfactory El E.coli present ❑E.coli absent No liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC !• ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci_ /100 ml. Method Code:SM 9223B [ISM 9222D Date and Time Received: o'}Sy ❑SM 9215E ❑Enterolert® (p. 1.- -L Date and Time Analyzed: Vo.1..T,s Date Reported:6 Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 C 1 C DOH Fern#331-319(revised 01116) l �'