HomeMy WebLinkAboutWAT2023-00111 - WAT Application - 7/7/2023 WAT;-(1)_3 - bd \\\
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MASON COUNTY
Shelton,WA 98584
`l COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
°r._ Belfair:360-275-4467,Ext.400
',y j Budding,Planning rnvirommontnl Heath,Community Health ) Elma:360-482-5269,Ext.400
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: Ar, drew /S Date: / 7/').'3 .
Mailing Address: 12 S ) >!e-e S pv Phone: S3- O\ ' d ffi
Parcel Number: 3�-0 ---a —23 y 0 2.3
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more f2t., Building permit R(--..P Z,O 2.3 "64'2.C,V\
connections) 0 Division of land:
lit Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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. 4 dd 1 , (Y1\
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.
J:\F.H Forms\Drinking Water Revised 4/27/2021
Individual Water Well
44 Water well report(attached to application). Depth U ft.
f Well capacity Test (attached to application) l 6 gpm > e 0° 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 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
❑ 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.
CH 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 Environ. Health: r � Signatures: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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$. WATER WELL REPORT
0
ilce CURRENT
Vat1G h copy-Ecology, "copy-owner, ~copy-
ilrear.e.
ID Notke of Intent No.W 280107
Construction/Decommission("rein circk)
QX Construction Unique Ecology Well ID Tag No, RCA 527
In fission ORIGINAL INSTALLATION
lr►lo Water Right Permit No.
i,���3 Notice of Intent Number Barbara Andrews
_ PROPOSED USE ❑a Domestic 0 lndugrial ❑Municipal PropertyOwneName
0 ❑DeWater ❑Irritation ❑Teat Well ❑Other Well Street Address 1251 E Lads Dr.
C TYPE OF WORK:Owner's number of well(if mart than one) City Shelton County Mason
O i] New well ❑ Re000ditioned Method: 0 Due ❑Bared 0 Deivea
IP
fIll 0 Deepened Q Cable ❑Rotary l load Location SW__1/4-1/4 N W 1/4 Sec 22 ' 2 R 3 awn 0 Check
DIMENSIOMS:Di.raeter of well 6 iorbr� drilled $4 _ ft. (a,t,r Soil l REQUIRED) wor
wm 0 O"e
Dtrpth d caauolcted well� n
p CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec
t casing Owrded 6 • Diam.from +1 ft.to I2_ ft.
C Installed:d: ❑Liter installed • Diem.ftom ft,to ft. Long Deg Long Min/Sec
LID ❑Threackd • Diem.From A.to ft. Tax Parcel No.(Required) 32022-23-90023
6 r.Aecatl na ❑Yet CNo CONSTRUCTION OR DICOMMYt3WN NIOCEDOP2
a., Type of perforator used Formation Describe by cola.diameter,size et material sod structure,and the kind and
- -.- —SIZE of pars la.by - -in.rod so.of perfi Strom ft,to ft. nature of the materiel.in ads stratum penetrated,with at lame om.atry for mob change - -•
Scrams Yes No Q K-]'ac Location 77 of information. (USE ADDTRONAL SHEETS IF NECESSARY.)
Johnson MATERIAL FROM TO
41 Maaafaanrats Name Top soil 6 2
Type stainless Model No. Brown clay with gravel 2 14
14 ti ft tiara.5 slot Aix i 2 from 79 .to $4 ft.
Q Dian. Slot nix from_ ft.to ft. Brown sand&gravel 14 35
w tar.vel/Ftlar psdt.d: ❑ yes 0 No Size of gravd/and Sand&gravel with some water 35 50
Meterisls placed from it to
fl. Fine gray sand with water 50 58
ay, IFS
Surface Seal: 0 yes No To what depth? j ft Gray clay with I • 58 69
ibil Material used in seal Betonite Gray sand&gravel with water `69 84
Did any strata contain unusable water? , 0 Yea 0 No ''' '
t . Type of weld/ Depth of strata • ' . -
Method of seating strata off - •
PUMP: Mnufactwc?s Name GiUlds
OType:, sub . H.P.1/2 __ . _._
Z WATER LEVKSi Laod+urfeoe elevation above mean an level ft.
Static level 18 ft.below top of well note
1 Artesian pressurelbs.per square inch Dart
MIArtesian water is controlled by (tap,valve,sac.)
>1 'WELL TESTS: Dtrewdowa is amount water level is lowered below static level •-
g Wes a pomp tees made? 0 Yes 0 No If yes,by whan/
Yield: gallmin.with ft.drawdown after hn.
8 Yield: eels.withft.dnwdown after his.
Yield: pl/min.with ft.drawdown after hre. • N • 21
W fee wasy date(thus token os ode when pump tamed off)(water eevef msasuheel from weft - •?�c - -- -e�Tt .
411 wvtowanrksft Jr '
O Tine Water Love! Time Water Lava mac Water Lcvet .p .'
sues -i _.
N . nr
r'
E y
,l�,m
Date of tee �� COrri
a Bailer Teat plhn ft.drawdows after 1 hrs. r --® (T
16 m.with 45 -,
8 Airiest pl./min.with Mtn set at ft.fa hrs.Amnonflow g.p.m.Date
co Temperitum of water Was a chemical snalysis made? ❑ Yes a❑No h Start Date 5/14/11 Completed Date 5/1gill
t
~ .WEI:LCONSTRUCTION CERT1F1CATION:1 constructed and/or accept responsibility for Edon of this well,and Its compliance with all Washington well
construction standards.Materials used and the information reported above are trot to my best knowledge and belief. .
QDrineitl OTrainee.Name ()Matt ennirtg• Drilling Company Davis Drilling • h
1
Dri1 eiEngineerarainee Sign ' Address 340_NE Davis Farm Rd. •
Driller or trainee License No. 307 City,State,Zip Belfair , WA 98528
IF TRAINEE:Driller's License No:
Contractor's
Driller's Signature: Registration No, DAVISI)I 11OOA Dace May 2011
6)CY 9.50;/-90,(1.47 00/08)If you need t tl i,a acianerfl Ih Pt per;atilt the Water Resources Pro
gram,at 360-407-6600.
r. .. Ffersdrit.arrlh hearing lass raw till07i11 fee.11/aghMRiibrtR Sitevlat. Parsons with a speech disablllty can call 877-833-6341.
Printed Tram Mason County DMS
( SPECTRA Laboratories- Kitsap
...Where experience matters
•COLIFORM BACTERIA ANALYSIS FORM•
Date Sample Collected Time Sample County
I 2-17 Collected
M�j,(�fl y
° Month Day Year W ❑pM 1 — !V'
Type of Water System(check only one box)
( 0 Group A 0 Group B Other
Group A and Group B Systems-Pr vide from Water Facilities Inventory(WFI):
an
ID# I \r\ {Q,W QV)(
System Name:
Contact Person:Nicholson Drilling
Day Phone:(360)876.4421 Cell Phone:
Email:office.nicholsondrilhng@gmail.com Eve.Phone:
Send resjrs t;_"k t name.add•tns an:i D»e a eman above for electronic xpy of rated1
bnttny.n,choisondnn.^;Zgr'a:•:.ccm
cahflton.nicholsondriliing@gmail.com
SAMPLE INFORMATION p
Sample collected by(name):�('T� (4" S _,,. V-41
Specific location where sample collected: Special instructions or comments:
Cc
Type of Sample(check only one box)
1.0 Routine Distribution Sample(AIP) 2.0 Repeat Sample(AlP)
Chlorinated:Yes ❑ No❑ (from disblbution system after unsat.routine)
Chlorine Residual:Total__--Free Unsatisfactory routine lab number:
3.Ground Water Rule Source Sample ——— -
S i I Unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered (AIP)
❑Assessment(AIP) Chlorine Residual:Total Free__
4.Surface o WI Raw Source Water Sample(Enumeration) I I
S
0 oil ❑Fecal Fdsered Ya: so`
5. Sample Collected for Information Only:
LAI3 USE ONLY' DRINKING WATER RESULTS• LAB USEONLY
ID Unsatisfactory Total Coliform Present and preratisfactory
❑E.cofi present 0 E.cofi absent /
Bacterial Density Results:Total Coliform mpn/103rn1.E.coli mpnl100m1.
Fecal Coliform ... cfu/100m1.
Replacement Sample Required: 0 TNTC ❑Sample too old
❑ Sample Volume 0 Damaged Container 0 _
Datgnw 4e7ve2 1 / ./[ Lab Reference Numper,
Receipt Temp C°: Melhod C M922 COUNT/SM9222D
Date Reported mAA-2-0-323-----~•rnrtat 4 i'aa'mNy fa the u„ato a„w,or cal;any b
Mon II Is adaasad.M/u a.wing a asdosae 02W emn by em
it anEed is aoNrn bed.a you hero ramp d Se War
�j(� am.pbeee taffy an ser;r em adaldy at 36Ps43.7O45 rre
Doll Lab—Sample .•� ! 1 }}() aaaror llr, pal l,�nxy
(✓ 7.a.N,ya*ea oNy.Pe,Mn,'natled sal onrxd.blo a,
O'�O- 7r m ielad byM�.b was Tan KVrre ea eodr,1 .xpr
J-- in fu0 alndA Nea a,prsss asi9an ptfcvd by Sprrae L
DOH tam g31J4(efaµre MU)