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Home My WebLink AboutWAT Application - 5/10/2023► • f - . WA-NMI:h ✓ 0 0 MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6t1i Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •) Elma: (360)482-5269 ext 400 FAX(360)427-7787 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: Cameron Jurgensen Date: 5/10/2023 Mailing Address: PO Box 791, Allyn, WA 98524 Phone: 253-380-9250 1 Parcel Number: 2217.14 00050 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit -5 id 2023 -00623 connections) 0 Division of land: 0 Individual water source (one connection), #of Parcels? SPL 0 Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ Other(explain) 0 Replacemen or Remodel( lease indicate name If you have more than one residence connected of water syste • pplicable-no to this well, check the Public/Community Water signature required System box. , / `� Part 2: Water Connection Information p� Complete the section appropriate for the type of water connection being evaluated: Public Water System Nam- of Water System: Well Tag - AGL302 Water Facility - • WFI) Number: AGL302 (write"none" for two-party 0 I am the manager of this water syste e wate -m has been approved for 1 services. There are presently 1 coy ection(s) in use. This • -- the 1 connection. 0 I am the manager of this s em. This connection will be to upgrade or :..e the use of an existing connection on this sy -m (i.e.: recreational to full time). Please indicate on the : .wing line the nature of this change: This water em is able and willin to pro ide ater to this (these)connection(s)without exc-- -. g the limi if the water system or y I mits s- by .tate and local regulation. Sig - ure of Water System Manage ,,r i Date dC, M c5-1,P-'5 This form may be scanned and available for public view at www.co.mason.wa.us. J:1E111 Forms\Drinking Water Revised 1/25/2018 f f Individual Water Well O Water well report(attached to application). Depth 90 ft. ❑ Well capacity Test(attached to application) 16 gpm ?8 0 d 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. 0 Satisfactory bacteriological test(attach to application). "// b Z3 Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 1 i 74 151-1 16r-1 22= Water use or limitation recorded N/A i II Yes El Well Drilled Date 743O16 5z 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) VSatisfactory 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 Manager�l�tpp Bents may apply. Chapter 36.70A RCW. �J �V Li Unsatisfactory Determination: laPir Eri Applicant's water supply does not appear adequate to meet the needs of its int se for the following reason(s). tyASON � � 2023 COthNTYENV/RONMENT Reviewer's Signatures: DJA AL HEALTH Environ. Health: Date f(36��Z3 2"1' CSD Director: Date / WI WATER WELL REPORT CURRENT' o Intent No. W 139852 r c.I.„6'r Original& 1st copy-Ecology,2nd copy-owner,3rd copy-driller Unique Ecology Well ID Tag No. ACT. 302 Construction/Decommission(x"in circle) '' Q Construction Water Right Permit No. 5 0 Decommission ORIGINAL CONSTRUCTION Nonce D1 D 9S�5 of Intent Number Property Owner Name Brenda P 1 n P PROPOSED USE: [1 Domestic ❑Industrial ❑Municipal Well Street Address 790 E North Bay Rd. - ❑DeWater ❑Imgauon 0 Test Well ❑O more thanther Mason LICity Allyn County: a TYPE OF WORK: Owner's number of well(if one) EWM circle n ®New Well ❑Reconditioned Method. ❑Dug ❑Bored ❑Driven Location SE 1/4- 1/4 ��l/q Seen-- Twn 22_ R1TnL or one 0 Deepened In Cable El Rotary 0 Jetted- Lat/Lon : WWM DIMENSIONS: Diameter of well 6 inches,drilled 98 ft. (s,t,r still Lai Deg Lat Min/Sec 7 Depth of completed well 90 ft REQUIRED) Long-Deg Long Min/Sec Tax Parcel No. 1 2 21 7—1 4—0 0 0 5 0 5 CONSTRUCTION DETAILS 3 Casing ®Welded t " Diam from 0 ft to_$5_ft CONSTRUCTION OR DECOMMISSION PROCEDURE C Installed: ❑Liner installed Diam from ft to ft Formation.Descnbe by color,character,size of material and structure,and the ❑Threaded Diam from ft to ft kind and nature of the matenal in each stratum penetrated,with at least one entry for each change of information.Indicate all water encountered Perforations: ❑Yes No (USE ADDITIONAL SHEETS IF NECESSARY) Type of perforator used _ __ .- -_ _,-____ ___ _-______,...z- —.-__-._MATERIAL .„FROM ,.o.,,.,T.Oa..lr,..r..„, D SIZE of perfs in.by in and no of perfs from ft to ft 3 Screens:0 Yes ❑No I K-Pac Location 83 Manufacturer's Name Cook 3 Type stainless Model No Top soil 0 4 Diam 5 Slot Size 3 Q from 85 ft to 90 ft Q Diam_ Slot Size from ft to ft Brown conglomorate 4 42. g Gravel/Filter packed: ❑Yes ❑No ❑Size of gravel/sand ' Q Materials laced from ft to ft � p Gray conglomerate with D Surface Seal: []Yes ❑No To what depth? 18 ft water 42 6 9 3 Matenals used in seal Be toni to • >, Did any strata contain unusable water? ❑Yes ®No • Blue sand & silts with - - Type of water? Depth of strata water 69. 78 C Method of sealing strata off C PUMP: Manufacturer's Name Rrnwnsandr_ a 1 _ Type"_ H.P 8 gray a. with water - • 78 98 - — WATER LEVELS: Land-surface elevation above mean sea level -ft - Static level Flows ft below top of well Date Artesian pressure lbs per square inch Date - _ n Artesian water is controlled by _i i (cap,valve,etc) O —O 3 WELL TESTS: Drawdown is amount water level is lowered below static level. Was a pump test made?❑Yes ®No If yes,by whom? .-• ,- i rr; Yield gal/min with ft drawdown after hrs - - • - - �r .. h •- _ Yield• gal/min with ft drawdown after hrs t mr1 Yield gal Irmo with ft drawdown after hrs VRecovery data(time taken as zero when pump turned off)(water level measured front ., ?f 7 well top to water level) 0 5 Time Water Level Time Water Level Time Water Level .II: :n ON - 73 Date of test - 3 Bailer test 16 gal/min with 2 5 ft.drawdown after 1 hrs a Airiest gal/min with stem set at ft for hrs 3. Artesian flow g p m Date Temperature of water Was a chemical analysis made? ❑Yes ID No Start Date 1 2/1 0/01 Completed Date 1 7/3 0/01 ✓ WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all - Washington well construction standards.Matenals used and the information reported above are true to my best knowledge and belief. - El Dnller ❑Engineer ❑Trainee Name(Pn t) EdHu i l Drilling Company Davis Drilling Driller/Engineer/Trainee Signature ,t Yh Address #4 0 • NE Davis Farm Rd. Driller or Trainee License No. 2 4 9 9 City,State,Zip Be l f a i r, WA 98528 Contractor's If trainee,licensed driller's Registration No DAV I SD I 1 1 006.ate • Dec. 01 Signature and License no. Ecology is an Equal Opportunity Employer ECY 050-1-20(Rev 4/01) rcu rL" Thurston County Environmental Health Li i. 3 U 2O030 La eridge Dr.SW t Olympia,WA 98502 ED360 867-2631 • COLIFORM BACTERIA ANALYSIS Time Sample 1 6 Date Sample Collected Collected County 11 ixY,1)-g 1/ii ,A 0 km Moan Month Day Year Type of Water System(check only one box) 0 Private Household •_ Grou B .7 Other 1N 1� ❑Group A ❑ p Group A and Group B Systems-Provide from Water Facilities Inventory(WFI). ID# System Name: Contact Person 4'. rlgEgibiaiVZIIIIIIIIIIIIIIIIIIIIII Day Phone:( ) Eve.Phone:( ) d results t..(P'' ull n address.nd zip code or email address) SAMPLE INFORMATION Sample collected by(name): mcsoil J V _ rC � Specific location or address where sample ollected: Special instructions or comments: -Tio e Jar \?x j 0.--(') Type of Sample(must check only one box of#1 through#4 listed below) 1. Routine Distribution Sample 2.Repeat Sample(after unsat.routine) No 0 Distribution System hlorinated:Yes Chlorine Residual:Total_Free_ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total_Free_ ❑E.col!-GWR(A1P) 0 Fecal-surlace,Gwi.springs lnumeratiord Unsatisfactory routine lab number: Filtered:Yes_—No__ __ — - -- —_ ❑Assessment Monitoring(NP) Unsatisfactory routine collect date: ❑Other I I S I 4.0 Sample Collected for Information Only Other Investigative_. _ Construction I Repairs ;USE ONLY LAB USE ONLY DRINKING WATER RESULTS PI atisfactory ❑Unsatisfactory Total Coliform Present and o C•liform detected ❑E.col!present ❑E.coli absent Replacement Sample Required: 0 0 Sample too old(>30 hours) 0 TNTC 1100m1. E.col!__--1100m1. Bacterial Density Results:Total COliform__---- f100 ml. / -- Fecal Coliform__-100m1 Enterococci_ Da Time Received:I1)30 I Method Code:`ie a s SM 9223B 0SM 9222D (Y�rl"q is SM 9215E 0 Enterolert0 �i • Date Reported: •1-23 k Date and Time Analyzed: Lab Use Only: Sample Number(DOH number plus five digits) oot't__FQrm 4331-319(revised 01116) - (W2-1