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HomeMy WebLinkAboutWAI2023-00056 - WAI Health Waiver - 5/31/2023 • 415 N.6`h STREET,SHELTON WA 98584 • MASON COUNTY SHELTON:360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269,ext.400 Building,Panning,Environmental Health.Community Heath FAX:360-427-7798•/ 1101iiiiii for Waiver or Appeal Amount Paid: Receipt Number: WAI Instructions: 1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed. 2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1. Applicant & Parcel Information Name of Applicant Richard & Holly Mullen Telephone (253) 230-3718 Mailing Address PO Box 81 City Grapeview, State WA Zip 98546 Parcel No. 2 2 1 1 3 5 1 -- 0 0 0 0 5 Site Address 51 E Cormorant Place, Grapeview, WA 98546 Subdivision Name and Lot McLain's Cove TR 5 & T.L. PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver 0 Food Sanitation Requirements ❑ Onsite: Class B Waiver 0 Group B Water System Regulations O Onsite: Class C Waiver 0 Water Adequacy Requirements Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies O Onsite: Holding Tank, WAC246-272A- 0 Appeal:Enforcement Timelines 0240 0 Appeal:Departmental Determinations O Onsite: Contractor Certification 0 Other Requirements Description of Waiver/Appeal (include justification, additional material may be attached.): Waiver Sought: Reduce horizontal separation between primary and reserve drainfields and neighbor's well from 100'to 75'. Mitigation Measures: Septic system proposed is an OSCAR X02, which meets Treatment Level A without disinfection. General direction of slope is away from the well.Area well logs are attached and neighbor has been notified via certified mail. Documents are attached. Applicant Signature: h\c)-11---\ Date: 5-31-23 �] � �p o Pee iscd 8'1 32u1S This form may be scanned'and available for-public view on the Mason County Web site. Page 1 oft PART 3: Public Health Evaluation (Staff Use Only) L U ca 1 1. Type of Determination Required: Type of Onsite Waiver (if applicable) 1: Appeal 'Waiver None required Class A Class B Class C 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision): 3. Nature of Appeal:h6r.W/4 /a i sep W( i,cr't be/vCVM dvom j e Id aka wel/ �fcrn-) /Go'¢o 7S 4. Hearing Official: ❑ Board of Health 0 Health Officer O Pollution Control hearing Board 0 Public Health Director O Certified Contractor Review Board lir Environmental Health Manage 5. Mitigating Factors: we/ii 1.1 nut gout/opradrkeel f of the, dra1Op lcf we-(1 1 (C a k tim -95' r� do tiles 00 92 X '? TLW s lit- siVem 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: Date: 6./ n7 PART 4: Determination of the Hearing Official t... The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. This decision is based on the following findings and conditions: 0 The hearing official has determined that approval of this request could potentially adversely effect public health and is hereby denied. This decision is based on the following findings and conditions: Health Official Signature: Date: /7‘/2„ Revised 8/13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 Arrow Septic Designs 171 E. Vuecrest Dr. Union, WA 98592 Kimberly Nguyen PO Box 35 Grapeview, WA 98546 May 31, 2023 RE: Richard& Holly Mullen New Septic with Well Waiver- Parcel #22113-51-00005 Dear Kimberly, This letter is to inform you that we are currently working on a septic design on the property next door to yours at for Richard& Holly Mullen located at 51 E Cormorant PI, Grapeview, WA 98546. The proposed waiver is to place the drainfield as close as 75 feet from your well on Parcel #22113-51- 00005 located at 41 E Cormorant PI, Grapeview, WA 98546. The standard setback is 100 feet, but the state and local health code allows us to lessen this distance down to 75 feet. To mitigate the setback reduction on this project,the septic system proposed is an OSCAR XO2 low profile mound septic system with timed-dosing. Also,the general direction of slope/drainage in the proposed drainfield area is toward Pickering Passage and not toward your well. The drainfield meets the 100 foot standard setback for Pickering Passage and we are not asking for a reduction there. The proposed system meets treatment level A without disinfection, a higher standard than the treatment level B required. You do not need to respond to this letter, it is for notification only, but you can feel free to contact the local Health Department or myself with any questions. The Mason County Health Department regulator contact information is as follows: Mason County Department of Health Services 415 N 6th St Shelton, WA 98584 (360)427-9670 ext. 400 front desk If you need further information, please contact my office at paulaj ahctc.com or(360) 898-2255. Sincerely, U.S. Postal Service"` CERTIFIED MAIL) RECEIPT m Domestic Mail Only = For delivery information,visit our i• tie at www.usc.:.vrn 1` V JE• T As Paula J. Johnson N �I . A_ ` y Licensed Onsite Wastewater Treatment System Designer m (Certified Mail Fee $4.I5 �2 0- 6Qs r` is � ''' Extra Services&Fees(check box,add fee-_- •r..-. � I,z�•r`/ D ❑Return Receipt(hardcopy) $ - - ✓ D ❑Return Receipt(electronic) $ *•A00 .{,? p - D ❑Certified Mali Restricted Delivery S •-00 Here •"� 1 ❑Adult Signature Required S o.oa•`a� ['Adult Signature Reelected De'.very S D Postage 84.7J G� s ru Total Postage and Fr..,.25 tf' �202 ©01;7 [` Sent To '' __ nn N Street and Apt. or fib x ‘tkal\T . � :\L- S - S(--�3 v oX �S CASS‘fG, city, rare,ziP+ae C� I- AcrS �LQ' (old IL O . Q N0 WATER WELL REPORT CURRENT wz37oaz �EiVP� O 6c i"co -Ecology,2"co -owner,3 copy-driller Notice of Intent No. n•. 3 „ ,,, Original copy o[Y. copy PY E C 6i t 0ii ?G Y ALG218 I to 1 900 y Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No. C �' Q Construction Water Right Permit No.EXEMPT WELL Dee u'ashinot,,,._ Sr I ❑ Decommission ORIGINAL INSTALLATIOtN Notice Property Owner Name EDWiN&SHARON PAYNEpa�enr r;f are C0 '121i,2 of Intent Number "eo10 / !^ Well Street Address 2492 F. GRAPEVIEW LOOP ROAD C PROPOSED USE: m Domestic 0 Industrial 0 Municipal City GRAPEVIEW County MASON O 0 Dewater 0 Irrigation 0 Test Well ❑Other a.a Location NVI/4 U4 NVrl/4 Sec 18 T t21N R IW EWM ❑urde R TYPE OF WORK: Owner's number of well(if more than one) or ,/ orre WWM E ®New well ❑Reconditioned Method:❑Dug 0 Bored 0 Driven Lat/Long(s, r Lat DegLat Min/Sec O ❑Deepened 0Cable ❑Rotary ❑lotted Still REQUIRED) w DIMENSIONS: Diameter of well 6 inches,drilled 92 ft. Long Deg Long Min/Sec C Depth of completed welt 92 tL 111/ CONSTRUCTION DETAILS Tax Parcel No. 121182290033 ,C Casing m Welded 6 - Diam.from +1.5 ft.to 87_ ft. ++ !Walled: ❑Liner installed " Dian.from ft.to ft CONSTRUCTION OR DECOMMISSION PROCEDURE >` ❑Threaded Diam.from ft.to ft. O Perforations: ❑Yes mNo Formation: Describe by color,character,size of material and structure,and the kind and nature of the material in each stratum penetrated,with at least one entry for each change of ID Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY.) C SIZE of pert in.by in,and no.of peers from_ft.to ft.AS MATERIAL FROM TO Screw: ®Yes ❑No m K-Pac Location 85 BROWN CLAY 0 5 CO ,a„t Manufacturer's Name JOHNSON BROWN SILT BOUND SAND,AND GRAVEL, 5 tQ Type SLOTTED Model No CEMENTED 63 C) Diem.5 Slot size 016 from 87 ft.to 92 ft. CD Diana. Slot size from ft.to _ ___ _ _ft. GRAY SILT BOUND MEDIUM TO COARSE 63 Gravel/Filter packed:0 Yes m No 0 Size of gravel/sand SAND 83 Materials plead from R.to ---__ .__R• BROWN SILT BOUND SAND AND GRAVEL 83 87 +�+ Surface Seal:©Yes ONe To what depth?27 ft. SAND,GRAVEL AND WATER 87 92 C Material used in seal BENTONITE CHIPS LDid any strata contain unusable water? 0 Yes m No U. RI Type of water? _Depth of strata_ Method of sealing strata off F"" PUMP: Manufacturer's Name O Type: H.P. Z WATER LEVELS: Land-surface elevation above mean sea level ft. th Static level 44 ft.below top of well Date.2/27/06 O Artesian pressure lbs.per square inch Dale �0 Artesian water is controlled by (cap.valve,etc.) WELL TESTS: Drawdown is amount water level is lowered below static level OWas a pump test made?0 Yes la No If yes,try whom? Yield: _gal./min with ft drawdown after hrs. 0 Yield: gal./min.with ___ ft.drawdown after hrs. 0 Yield: paL/min.with __ft.drawdown after _hrs it,l.t Recovery data(rime taken as zero when pump turned o )(water level measured from well O top to water/ere° Time Water Level Time Water Level Time Water Level , iaa C --- - — - --_._ 0 EDate of test LBailer test I O gal/min.with 14 ft.drawdown after 4 hrs. QAiriest gal./nun.with stem set at ft.for hrs. tl) Artesian flow__ g.p.m Date CI Temperature a of water _Was a chemical analysis made? 0 Yes m No d Start Date 2/21/06 Competed Date 2/27106 wC H 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 the information reported above are true to my best knowledge and belief. O Driller 0 Engineer❑Trainee Name(F r• )MA K . EL N Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature �r - Address PO BOX 1790 Driller or trainee License No. 1992 City,State.Zip SHELTON WA 98584 if TRAINEE, Contractor's Dryer's Licensed No. Registration No. ARCADDt098K1 __Date 2r28l06 Driller's Signature ECY 050-1-20(Rev 3/05) Ecology is an Equal Opportunity Employer. File p Oripint sad ologyCopy with WATER WELL REPORT F-, star,Card No ___ o$25?s._.. SeOond Copy-Owners Copy STATE OF WASHINGTON `D Third Copy-Oriller's Copy water Right P'ermn No _ +"r OWNER: Name aQb a� _.- ._- Address F 4FI0 S tie' i urn BPAGh Rd F GrApevi el,/ WA_ G (1) ._, w (2) 1OCATION OF WELL: County Mason.. — E s SE %sec 13 T. 21 N..t�2W W.M. (2a) STREET ADDDRESS OF WELL(or neareat address) E 460 Stadium Pear.] Rc) .E Grapevi aw WA 98S4b---.......... -- W (3) PROPOSED USE: 1C3 Dorneelic Industrial C Municipal f1 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION D Irrigation 0 D*Waler Teat Well E Other (-1 Formatioo: Describe by color, character, sae of material and structure, and show (A Etudes oEtudes and the kind and nature of the materiel in each stratum penetrated. ..... (4) TYPE OF WORK: Owaar's somber of welt with at Waal One emry for each change of information. ill more than one) -----mAr—Er---AL.. YATER{Al F7rOr TO Abandoned New well IX Method: Dug Li Bored 2 - - -- O Deepened r l Cable I X Driven Reconditioned '. Rotary r: Jetted ... Brown conglomorate : 0 .5..... C C (5) DIMENSIONS: Diameter of well 61' inches. -- 20 R milled__ 120 feet. Depth of completed well 190 n. Brown clay __—. I —5 £ (6) CONSTRUCTION DETAILS: Sand &_gravel with some water _ i 20. _ _22 w Casing Instatted: ...... 6 • Diem.from_ fl h to .115 h. Welded l74 • Diam.from n.Io—_.__—tt- Hardpan —_--_ _ 22 30 Liner metalled _ CD Threaded ... • Diam.from ft.t0 ft. vC 4.0 Palrforatfons: Yes E No0 Blue Clay .... - _ --. 30_.. -45..... O Type of perforator used_ ---- .a SIZE of perforations _..___-in.by in. Hardpan 45 80 C _.__-_perforations from _.__It.to ft. 1 R perfwetionafrom ft.to n. Sand & gravel with water 80 i 120 - perforations from ft.to ft 1 p Screens•. Yee3 No❑ r- f i Manulactwer's Name C,nnk . ____ Type SfA7Dlr'SS Modal No - -------...--•- ---- -- r Diem. Sit Slot size 30 from 115 n.10 120 n. W..f Diem.. Slot size front ft.to n. c �1 I iGravel packed: Yes❑ Nolat Size of gravel L R Gravel placed from h.to ---_—ft. - Surface teal: vas® No❑ To what depth? 18 ft. . - `- O Meteoriteeed iseal Betonite -- __. - - r i Did any strata contain unusable water? Yes❑ No —'------ --._._ - --•-' ---- - ---.. rZ .--- .. .._ .- .. _.. _--. _...-_.....--- . Type of water?_ -_- Depth of strata H Method of sealing strata oh-......... ___.__-___.-... --- ..... . .-.. _—..--_—. .._._._ . 42) i t 1df as '---- .. ... _ .. ._... , ._.. • (7) PUMP: Manutacturer'eHame Gr_---- >s Type: sub. H.P. _1 r • (8) WATER LEVELS: �and•surtaceele»+on _ _ above mean sea:y __h. O Static level 85 _ ft.below top of well Date j _ V Artesian pressure loa.per square inch Date r LU Artesian water Ia controlled by. (Cw wlw,arc,)) ._. ...._. %I'e WOW'et _ In/ll/�1.__.te. Completed 1l1/15/Q1 •t9 0 (9) WELL TESTS: Drawdo��w'lln is amount water level is lowered below static level J..f Was a pump test mede?Yee NO If yes,by v hom?___ � _ WELL CO�TRUCTOR CERTIFICATION: tU Yield: -.- gal.taint.with_ _., ft.drawdown atter _.hrs. E _ I constructs and:or accept responsibility for construction of this well, and its compliance with all Washington well construction standards. ++ — — '• Materials used'arid the information reported above are true to my best flf Recovery date(em.taken ss moo when pump turned off)(water level measured knowledge and belief. IQ Iron well top to wow Ave* t) ume Winer Level Time Water Lew rims water Lime' . G NANAME (PERSON.EiRk4.OR' ,�QQ CORPORATION) (TYPE OR PRINT) 41.8 --� _ Address __Beifair WA__9.8528 Date of test ----._._... 1884 C (Signed)—_�� License— No. Sorter tell. 20 gal./min.with_�1-_ft drawdown utter 1 hrs. (WE ILLE Contractor's Airteet_.._ .--gal..min.with stem set al_ fl.for hrs. Kall.Q07 Artesian flow_ _ _g.p m. Date_ NO.ts�'+V LS�1 1 oats' Jac t.--_ .t o 91 Temperature of water___ Was a chemical analysis made? Yes❑ NoLig (USE ACDITtONAL SHEETS iF NECESSARY) 0 ECY 050'20 (IC sr) 1329 1 • /O'OO Al 6-00221 2- WATER WELL REPORT CURRENT re Original&In copy-Ecology,2ie ropy-owner,3e°copy-driller Notice of Intent No.WE 14058 DEPARTMENT OF d ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No.BHH 040 on ® Construction Water Right Permit No. N ❑ Decommission ORIGINAL INSTALLATION __ Notice of Intent Number Property Owner Name D J Miller LLC PROPOSED USE: El Domestic 0 Industrial 0 Municipal Well Street Address jMcLane Cove) O 0 Dewater 0 Irrigation 0 Test Well 0 Other City Grapeview County Mason = TYPE OF WORK: Owner's number of well(if more than one) O ® New well 0 Reconditioned Method:0 Dug ❑ Bored ❑ Driven Location SSE 1/4-1/4 SE 1/4 Sec 12 Twn 21 N R 2W EwM C) �• + 0 Deepened 0 Cable 0 Rotary ❑ Jetted (s,t,r Still REQUIRED) or Lis DIMENSIONS: Diameter of well 6 inches,dri11ed134 ft. WWM el EDepth of completed well 13111. O CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec tth" Casing El Welded 6' Diam.from +1 ft.to 126 ft. Long Deg Long Min/Sec C Installed: 0 Liner installed " Diam.from ft.to ft Tax Parcel No.(Required)221124400300 61 0 Threaded " Dram.From ft.to ft 4.1 Perforation': ❑ Yes El No CONSTRUCTION OR DECOMMISSION PROCEDURE t.. Type of perforator used Formation:Describe by color,character.size of material and structure,and the kind and O SIZE of perfs_in.by_in.and no.of perfs_from_f,to ft nature of the material in each stratum penetrated.with at least one entry for each change of information. (USE ADDITIONAL SHEETS IF NECESSARY.) Screens: ® Yes 0 No ® K-Pak Location 125 MATERIAL I FROM TO AI Manufacturer's Name Alloy machine Works Brown silt,soft,dry 0 2 .� Type Stainless Slotted Model No. Brown gravelly fine sand 2 Q Diam.5"Slot size.018 from ft to atit tight.dry 33 Diam Slot size from ft.to ft. Gray gravelly fine sand 33 a GGravel/Filter puked: 0 Yes Callo Size of gravel/sand tight,dry 38 t Materials placed from R to ft L. Brown gravelly fine sand 38 Surface Seal: IS Yes 0 No To what depth?20R tight.wet 45 C Material used in seal Bentonite Chips Gray clay,stiff,dry 45 52 ` Did any strata contain unusable water? 0 Yes ® No Gray gravelly fine sand 52 - Type of water? Depth of strata silt bound,tight,dry 69 eu Method of sealing strata off Gray silt,soft,moist 69 75 PUMP: Manufacturer's Name Brown silt,soft,moist 75 84 0 Typo: H.P. Gray sticky day,dry 84 87 z Gray fine sandy silt,soft 87 WATER LEVELS: Land-surface elevation above mean sea level ft. moist 99 Static level 71R below top of well Date 01/09/2012 ali Brown gravelly medium 99 O Artesian pressure lbs.per square inch Date — sand loose,wet 118 ID Artesian water is controlled by (cap,valve.etc.) Brown medium sandy gravel 118 WELL TESTS: Drawdown is amount water level is lowered below static level tight,wet 131 CD O Was a pump test made? ❑ Yes El No If yes.by whom? Brown sharp gravel tight 131 O Yield: galJmin.with ft drawdown after hrs. dry 133 C) Yield: _ gal./min_with ft.drawdown after Errs. LIJ Yield gal.imin.with_ft.drawdown after hrs. (� p h O Recovery data(time taken as zero when pump turned all)(water level measured from At��Ir—! I p well top to water level) w ,�a..r C Time Water Level Time Water Level Time Water Levet `� r) 7 ,n .- Cl JAN L.3 Lu L EWA ` rp,i.e f70ci:.,rmer,+ V5 Date of test fl! EC+Ci1og j' is Ali no) O. Bailer test gal_/mitt_with ft drawdown after_hrs. 1 Ci Airiest 2Q2aL.hnin.with stem set at 100R for 1 hrs. Cl Artesian flow a.p.m. Date Start Dale 01/06/2012 Completed Date 01/09/2012 I— Temperature of water 51 Was a chemical analysis made? ❑ Yes ® 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 the information reported above are true to my best knowledge and belief. IS Driller 0 Engineer❑Trainee Name( . gentry Phythian Drilling Company Arcadia Drilling Inc. Drillt:r/Engineedfrainree Signature Address Po Box 1790 Driller or trainee License No.2053 City.State,Zip Shelton , Wa, 98584 IF TRAINEE:Driller's License No: Contractor's Drillei s Signature: Registration No. ARCADDI09SK I Date 01/11/2012 ECY 050-1-20(Rev 02/10) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. boa V WATER WELL REPORT Start Card NO. W072833 Unique Well I.D. 8 ACQ302 STATE OP WASHINGTON Water Right Permit No. i.; L Address a 2191 03tAPEVIEW LOOP GRAPEVINE, WA 98546- Q (1) OWNER: Name CEONCE, GARY LOOP -_ - CD (2) LOCATION OF WELL: County MASON - NE 1/4 NE 1/4 Sec 13 T 21 N., R 2W WM ce 12a) STREET ADDRESS OF WELL (or nearest address) E 2191 GRAPEVIEN LOOP, GRAPEVINE c WIWI CD (3) PROPOSED USE: DSTIC OME (10) WELL LOG (4) TYPE OF WORK: Owner's Number of well Formation: Describe by color, character, size of material QD (If more than one) and structure, and show thickness of aquifers and the kind .= NEM per, Method: CABLE and nature of the material in each stratum penetrated, with • - at least one entry for each charge in formation. C (5) DIMENSIONS: Diameter of well 6 inches FROM TO 0 Drilled 150 ft. Depth of completed well 150 ft. MATERIAL 0 3 C .-- ___= BROWN TOP SOIL HROIQi TILL SONE COBBLES 3 13 0 (6) CONSTRUCTION DETAILS: 13 17 i+ Casing installed: 6 " Dia. from .1 ft. to 144 ft. BROWN TILL CLAY BINDER , 13 31 03 WELO= CASING " Dia. from ft. to ft. BROWN TILL SOWS COBBLES 1 E " Dia. from ft. to ft. BROWN CLAY 31 31 39 .. j GRAY SAND BROWN GRAVEL 51 53 {� Perforations: NO 53 Se Type of perforator used SANDY BROWN SAND SIZE of perforations in. byin. GRAVEL & WATER COURSE 58 61 061 74 perforations from ft. to ft. GRAVELGRAY a WATER 74 84 Y • �'�`perforations from ft. to ft. 74 841 h. perforations from ft. to ft. PACE= BROWN GRAVEL 0 .... SILTY BROWN SAND 101 118 116 139 13 Screens: YES GRAY TILL 118 : 19 C Manufacturer's Name HOUSTON BROWN GRAVEL TRACE OP SAND WATER 03 Type SLOTTED Model No. R Diem. S slot size .030 from 142 ft. to 150 ft. Diem. slot size from ft. to ft. I 03 Gravel packed: NO Size of gravel CD Gravel placed from ft. to ft. depth?IWO 20 ft. i To what . Surface seal: YES _.+ Material used in seal BNNTONITE C Did any strata contain unusable water? NO 03 Type of water? Depth of strata ft. L h. Method of sealing strata off 03 = = s••• `n's=...... __ (7) PUMP: Manufacturer's Name == == -_ Type H.P. 0 18) WATER LEVELS: Land-surface elevation 4 Z above mean sea level ... ft. 0 Static level 124 ft. below top of well Date 10/10/94 CD Artesian Pressure lbs. per square inch Date I � 0 Artesian water controlled by 13 Work started 10/15/96 Completed 10/30/96 12) (9) WELL TESTS: DrewdOwn is amount water level is lowered below I WELL CONSTRUCTOR CERTIFICATION: 0 static level. I constructed and/or accept responsibility for con- 0 Was a pump test made? NO if yes, by whom? struction of this well, and its compliance with all v Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used and the information reported above arc true to my best III and and belief. oRecovery data __ Time Water Level Time Water Level Time Water Level NAME ARCADIA DRILLING INC. C: iPerson• fire., Or corporaticni (Type or print) C E ADDRESS S 170 W ER PARE RD Date of test / / 03 Bailer test 16 gal/min. 7 ft. drawdown after 1 hrs. (SIGNED) QK I^..''' License Nc. 1149 a Air test ga./min. w/ stem set at ft. for hrs.I CD Artesian flow g.p.m. Date ! Contractor's Q Temperature of water Was a chemical analysis made? M0 I Registration. No. ARCADDI098E1 Date 10/31/96 CD H