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Home My WebLink AboutUntitled (1967) e„ . � WAT o?O 023— 001245 i MASON COUNTY OW r COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health RECEIVED 415 N 6t''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 JUN - 8 2023 Application for Determination of Water Adequgcv W Alder Street 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 utEed.l RO N MENTAL 3. Submit completed application, with any required attachments for review. �'Vv t f� 4. An approved building site plan must accompany this application. HEALTH Tu Part 1: Applicant/ Parcel Identification 1 1 G [. ( 1 Ayr V�Applicant:-PK -r / Aie 6 q Date: Li + /6 •/�2 9Z3 MailingAddress:i 57 �SQI sr AVE , CT EA./� h e: Z53 S7'Z 4'b13 Parcel Number: 2.2./03 '5Z ^ 0 0034 Type of Water System Reason for Application❑ Public/Community Water System (2 or more X. Building permit 0L 2R A23—Oo�"�g connections) 0 Division of land: XIndividual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water ❑ Other(explain) 0 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) 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. ❑ 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J; lI Form,Drinking Water Revised I/25/201K Individual Water Well Water well report(attached to application). Depth `1(/ ft. t Well capacity Test(attached to application) lr gpm >800 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 5r1 16n 22[ Water use or limitation recorded N/A I ] Yes [i Well Drilled Date 6 .0 - 20/7 Individual Spring/Surface Water ❑ 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 • • Part 3: Mason County Community Services Evaluation (staff use only) 4 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). Reviewe ' Signatures: Environ. Health: • Date Or/-/ 2°'' CSD Director: Date Mrrnlrrr -AMMO g,�� a�1�CR� ENVIRONMENTAL WATER WELL REP C CURRENT HEALTH Original&l"copy-Ecology,2 copy- �r3 rn -d L D Notice of Intent No. W359627 DEPARTMENT OF ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No.BJT 918 ftaM d e/MNnjlen ® Construction JUN -8 2023 Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATION Notice of Intent Num r ► _ r S t f eGP)'Owner Name AA Properties PROPOSED USE: El Domestic 0 Industrial Municipal Well Street Address Nearest Address:850 Benson Lake Drive 0 DeWater 0 Irrigation 0 Test Well ❑ Other City Shelton County Mason TYPE OF WORK: Owner's number of well(if more than one) ® New well 0 Reconditioned Method:❑ Dug ❑ Bored ❑ Driven Location NWI/4-1/4 1/4 Seca Twn 21N R2W Ews 0 ❑ Deepened El Cable 0 Rotary 0 Jetted (s,t,r Still REQUIRED) or DIMENSIONS: Diameter of well 6 inches,drilled 99 ft. ww Depth of completed well Mft. CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec Casing El Welded 6" Diam.from +1 ft.to 92 ft. Long Deg Long Min/Sec Installed: 0 Liner installed " Diam.from ft.to ft. Tax Parcel No.(Required) 22103-52-00034 0 Threaded " Diam.From ft.to ft. Perforations: 0 Yes No CONSTRUCTION OR DECOMMISSION PROCEDURE Type of perforator used Formation:Describe by color,charmer,size of material and structure,and the kind and SIZE of perfs in. in.and no.of perfs from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change — by of information. (USE ADDITIONAL SHEETS IF NECESSARY.) Screens: ® Yes 0 No ® K-Pac Location 89 MATERIAL FROM TO Manufacturer's Name Johnson Brown Glacia Till 0 22 Type Stainless Steel Wire Wrap Model No. Tan Silt Bound Sand&Gravel 22 77 Diam.5 Slot size IQ from 91 ft.to Sand&Gravel water Bearing 77 99 Diam. Slot size from ft.to ft. Gravel/Filter packed: 0 Yes ID No Size of gravel/sand Materials placed from ft.to ft. Surface Seal: El Yes 0 No To what depth?1$,ft. Material used in seal Bentonite Did any strata contain unusable water? 0 Yes El No Type of water? Depth of strata Method of sealing strata off PUMP: Manufacturer's Name Type:Submersible H.P. WATER LEVELS: Land-surface elevation above mean sea level ft. Static level 60 ft.below top of well Date 6-16-2017 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump test made? 0 Yes ® No If yes,by whom? Yield: gal/min.with—ft.drawdown after hrs. Yield: galJmin.with ft.drawdown after hrs. Yield: gal/min.with ft.drawdown after hrs. Recovery data(time taken as zero when pump turned o))(water level measured from well top to waxer level) Time Water Level Time Water Level Time Water Level Date of test 06-16-2017 Bailer test 15 gal%min.with 11 ft.drawdown after 4 hrs. Airtest gal./min.with stem set at ft.for bra. Artesian flow g.p.m. Date Start Date 6-7-17 Completed Date 06-16-17 Temperature of water Was a chemical analysis made? 0 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. Drilling Company KNAPP DRILLING INC. ®Driller❑Engineer❑Trainee Name(Prim)Dwane Knapp Address E 50 Lesaca Dr Driller/Engineer/Trainee Signature City,State,Zip Shelton Wa.98584 Driller or trainee License No. 1706 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. KNAPPDI952B1 Date 06-23-2017 _ 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.