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HomeMy WebLinkAboutWAT2021-00351 - WAT Application - 4/25/2023 \RDA-W1 ,,, t ZozI - Co3V 1 115 N.6'h Street ', MASON COUNTY APR 2 5 2023 Shelton,WA 98584 Shelton:3G0-427-9670,Ext.400 COMMUNITY SERVICES ` � ,r 615 W. q� 13elfatr:360-275-44G7:Ext.at>a ;r>:: der Streett l►na: 360-a82-52G9.Gxt.ano Budding,Planning,Environmental tkelth Community Health 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: y.{0n� Oaf lye t(\la.in Date: e)r I3/Z-I Mailing Address: i s C •5i,ir}t'rAta c.}- Phone: ?jam-' s-Dcf-71 3y) Parcel Number: ‘?�2%2 I - �1 ' 1 UD 3 1 7-POe--'- occt- Ctilek WA 9 O.t.oto Type of Water System Reason for Application ❑ Public/Community Water System(2 or more i? Building permit-bid 2c0 -co+4 D 7tnections) 0 Division of land: Y'tIndividual . ater 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) 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. 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 any limits set by state and local regulation. Print Name of Water System Manager Phone Signature of Water System Manager Date 3ri �jd e scanned and available for public view at www.co.mason.wa.us. F Eattr l RrctScJ a.'_'7;"!ll?OrIT1S� � Printed from Mason County DMS Individual Water Well Iril Water well report (attached to application). Depth 4 o ft. t[VV Well capacity Test (attached to application) qpm 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/planninq 14 15 L' 16_22__ Water use or limitation recorded N/A V Yes Well Drilled Date U-/ mot 1 b Individual Spring/Surface Water 1 ❑ WDOE permit(attach to application) O 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 I • • Part 3: ason 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: • n. Health: kl"-AIOVA-ky Y�'JDate �bJ b' ')Envlro This form may be scanned and available for public view at www.co.mason.wa.us. t'�c L f� Drintec - s . .a a � asan County D . . Printed from Mason County OMS J'''`... WATER WELL REPORT M l.Part w 34606 o.►-oaa•aGp ..+cw_e�ti 4r STATE OF WASHINGTON woe,Weds P..*r (1)OWNER Naea HODaade Jim (2)LOCATION OF WELL Cower. Mann _ NW 114: NW IN Sac 21 T. n N.IL 1W W M. (2*)STREET ADDRESS OF WELL(.2 -area �Waa1 T.x1 Yaetea Rl Ake.We (3)PROPOSIO USE De.eeec: x I.dwaw: M��io�ldpi: NO!II�L LOO st ARANOONNORT PROCEDURE DESC PT)oN Imrylum. - PIAR 20�i2 •li p•+.++Sarft by aata.O.aase.We daerada w au.aam err dew+kamr Dow, Tea WeR. Omm Mdrr�pl iwtr.a■M1ru6riaawoW s.lwsa.n f4)IYFE OF WORK Owteet N+ye dtwdl Of 11111e•ate: Abendoeeek - Naw Well x Oat iard -:t Meled :r.S_1 .IATYIAL sew ro d cab : km: I bow Fill Dirt I an 0 is 2 R03e1 °"ad— Raar1. lord:— a B OWl SM.3IMI&ter as of Gravel u 2 a 20 ] Blom?Silt!Saul Gard,Had u 20 a 69(6)D1MEINS$ONS UeYr etwen: 6 - team Brown Silt A Sot Compaq err 69 w 711 Drilled _ 247 id.Osaa of ooaplard. 2a, ft ] Brawn Silt Sall!layers of travel a 71 ran—11 16)CONSTRUCTION DETAILS a Brown Sift.Free-Med.Sands or is r 9i CaslniMlstsiad a odds Campaw: 1 6" R 2td a r Brown Silt A Fine-Ma.Sands x ran Madan: adds Dun Ras R.a 0. a !Layers of Orare1,Compact w 91 a 4'eleni 6• 1, isdelli • Brown Silt! 1111 Tfr..I�d Filrcf1led.Salts CANNA er 111 a 121 to Brown Silt t Fine-Yed.Sands we I.. P.eaoralaa. Yes No X II Typed patinae wag A layers of Gravel I at in I1t us11 Brown Silt it ReaMtd.Sands Ia 138 Ih 158 SIZE of prfatre.e oast by: Waco If Boma Silt!Fine-Med.Gray Sander in 13i 1A 161 Samna Yes: X No 'a Gray Silt!Fine-Med.Sandi Ill (6$ 1'4 191 Maulaegae o Nsaae:_ tt Grey Silt!Fine-Mod.SandatTrams ofGored 1ar 191 lie 207 Type Widen Sad Medd No• u. Blown Silt!Fine-MetGtaq Sands we2f17 roe 221 Dam. 6' Ste Sian. 20 tree. 240 R. a: 24S O. Blue fiery WithFine Sands 1x 22) 1t1 2.19 Dam: ��. Sid Sin: from: R. a: 0. 1a Oar Silt!Fine-Met Salt Ili14.—. — 1• I Layent of Stall GtaIN Iw Omni pieta: Yes:_ No• e Sea se 2J9 IR 245 as tat . Gravel plied Wee. n. a: e. 21 air Sumac.Seel Yea : a ale e : To red D II 0. et ]Ie Stattnd tad 111 sat saisaise a- D )1'1 la clil I/113 El 1- ye Ded ay he awes?.IwaMt roe Ye :_No : ■ is ) a.. LP t I y -L. __ T1pe d mar". Dapa d strait ]s - _ Maabddedad Ana eftNi. MAR 2 8 `—fir--„ ] — m PUmp Ma..hurefs pan t+ Tye N►. a ]" :sifts 1 ]a--art..—_ e)WATER LEVELS '*= a. VICFrt, ( atw+a sea try Mrd 270 0. — S/1i�r +r be S lard. 102 R.Wee lapel led. 2-2046 10 •- •]a�-.w,— Sam ler...1 parrs. per Node lads. Deer. dad inlet 14A6 .J Cr.LPl.Ld 24046 A (9)WfLL Tun Orr.dew.is erg. toward Ma ear lead Is towe.railfeed . WELL CONSTRUCTION Wa.pimp es de? Yes :_No . e If yobs wbeT maw . 1 ort.l was amps CERTIFICATION Yield plane.wow R.dnwd.w dRar Sawn wi6 all W ear es od aro.well tadwr.m aaadwda ate..We mid.ar Nair. Reme.T d�era.(eta saki.a am.Aa peso wow et11(.Leta bed aaemed ban aw11 rfo.sala mend sawn en one a Ay ban talawl.dp and tW/d. Ira n ea�er Meal Newt 1011/V4O PUMP COMPANY,WC Tree Warr Lead __-- imam.trw spat Anna Fre a CO evera^1 Tires. Wier Levi. AMMOP.O.IkeYl, Wade. MII1 MOM Taut WadsLeadOra of TOILSipid Robert UMW Y Ue a.Ne. 111i2 tlade Tat I fat .A...._I S n era ie+r der ri 1 Iria- n lo^ Air we 'Wad win ern tan t R.far bars CowmanRapatra. OGIMALMOI pa SrStied34-611496 ix M Maim Bow II P a OM a.ei.d t e.^.e 4 Tasepal Nana?.�_._ � oM1/•saWt, yeas. tili4 i alwc.l oa l.s I rl.a]» `~tinier i �J 1 )i l 1 l;2 "� 1TTT • • • printed From Mason County DMS Printed from Mason County DMS NICHOLSON DRILLING INC. PUMP TEST NAME: Jim Williams DATE November 18.2019 SITE: XXX E ST RT 302 TIME I PRCL• 12221-31-90031 Belfair,WA 98528 WELL DIAMETER 6 'inches WELL DEPTH 2451 Feet PUMP MODEL PUM P MAKE TANK MAKE TANK MODEL Time Depth Draw Rate Time Depth Draw Rate Time Deopth Draw Down Rategpm „xay. To Down gpm to Down gpm Water Water Water- 40 184 0 88.3.33.0 660 0.0 _ __ . Static 95.7 0.0 1 1 12/.7 720 0.0 32.0 33.0 45- 184.0 88.3 20 0.0 2 143.7 48.0 50 184.0 88.3 7 7 0 0.0 Mil 3 155.2 59 5 60 184.0 88.3 4 164.9 69.2 70 0.0 900 0.0_ • 80 0 0 960 0.0 MI• 169.7 74.0 6 174.4 78.7 90 0.0 1020 0.0 7 177.5 81.8 100 0.0� 1080 0.0 8 180.0 84.3 120 0.0 1140 0.0 9 182.4 86.7 150 0.0 1200 0.0 10 184.2 88.5 180 0.0 1260 0.0 11 184.2 88.5 210 0.0 1320 0.0 12 184.2 88.5 240 0.0 1380 0.0 13 184.0 88.3 270 � 0.0 1440 0.0_ 14 184.2 88 5 300 0.0 1500 0.0 1500 0.0 15 184 2 88.5 33.0 360 0.0 420 0.0 1620 0.0 20 184 0 888 3 480 0.0 1680 0.0 25 184 0 86.3 0 0.0 1740 0 0 30 184 0 88.3 MI60 0.0 10, 0.0 um 1840 88.3_ RECOVERY Depth Draw Time Depth Draw Time Depth Draw Time D to Down aw to Down to Down Water t Water - Water 45 0.0 1 1677 720 t1 115.6 199 0.0 3 144.9 49.2 72 114.3 186 50 0.0 13 1132 175 60 0 0 4 136.6 40.9 14 112.4 16 7 70 0.0 5 1314 35.7 15 111.9 162 80 0.0 6 127 8 32.1 20 109 7 14.0 90 0.0 25 0 0 100 7 125.0 29.3 30 0.0 120 0.0 9 119 5 23.8 8 122.2 26.5 35 0.0 150 0.0 40 0 0 180 0.0 10 117.8® SIGNED BY: 'L �" Alan Myette-Pump Supervisor • • 'Tinted From Mason County Dvi , Printed from Mason County DMS Thurston County Environmental Health 2000 Laker idge Dr.SW •Olympia,WA 98502 360 867-2631 Till ltSIUV CI It.'N1% imomem-em~ COLIFORM BACTERIA ANALYSIS Dale Sample Collected Time Sample County or, /c1 023 Collected Montt Dal rem • __.....»0 Type of Water System(Check only one box) 0 Private Household ❑Group A 0 Group 8 other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI) System Name Contact Person +r j ,vI)S Day Phone (363) 5-09- 1 3f Cell Phone ( E-mail n e G r,/ ,,eve Phone ( ) Send results to TPnnl tti n e,address and rip cm,.(.4 eili,i 1YLess) Ji1.1 4 nl tre lit 'Ye`� . - .. it saw -SAMPLE INFORMATION Sample collected by(name) it I 'L I I�r Specific location or address where sampleW collected Special instructions or comments • 1.4IQLL HtNsz ? b. Type of Sample(must check only one box of#1 through#4 listed below) 1.0 Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chonnated Yes—__ No___--- ❑Distribution System Chtonne Residual Total—__Free_ Chlorinated Yes No 3.Raw Water Source Sample Chlorine Residual Total Free_.__ ❑E ci -GWR;AIP) ❑Fecal- Give wood(rumour; Unsatisfactory routine lab number rdieted Yes -.No _._ ❑Assessment Monibnng(A!P) Unsatisfactory routine coned date ❑Gtfier S 4 Sample Collected for Information Only `I���/� uivestgative_ Construcbon f RNpaus Other?�. e �- LAB USE ONLY DRINKING WATER RESULTS -LAB USE ONLYsokrracto� 0 Unsatisfactory Total Goldoni)Present end s r>fAUrm dNetbd E co*present ❑E aoa absent ^` Replacement Sample Required: snack,l,0,0 old(A 30 Isom!s) Ei IN IC ❑—� _.._.- Bacterial Density Resuns TotalColform __---._____/100ml Ecc>/i. ___----_-dt00nd Fecal Conform__ __..___It00ml Enterococra -r IiflO rid Menial Code SM 92238 ❑SM 92??D Data ens rime Received D ❑SM 92158 ❑Enteroler* S 15.2Z 5- 15 . 2 n�:h:e:�r S t Dale end lone Atiadyzed 7 Sample Ntm4w Ipxti molt*.('Ws t.e dgss) !-� tab Use OiN) 0 8 0 2� 7jV _ _ -DIY.