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Home My WebLink AboutWAT Application - 5/22/2022 WAT_`)i( 1 Fhb Y \ �' 415 N.6� Street MASON COUNTY Shelton,WA 98584 a 'j"".- COMMUNITY SERVICES Shelton:360 427-9670,Ext.Street \.. I _ �G Belfaur:360-275-4467,Ext.400 1t.* -. 4,+' Building,Planning,Environmental Health,Community Heahh 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: -ZA It D,s 2'c. M t ate: 03$• ZZ • 20SZ2 271s- IQwN ‘ s.e. Mailing Address: F,.n,,�4 ACAS ;\ CI. Phone: ZQ \ .‘QSQSS Parcel Number: 2.ZIZ3- ?S \19s Type of Water System Reason for Application / Q' Public/Community Water System (2 or more C' Building permit .&11.02,92,005112_ connections) 0 Division of land: 0 Individual water source(one connection), #of Parcels? SPL O Well 0 Boundary line adjustment O Spring/surface water 0 9Ither(explain) 0 Other(explain) Replacement or emodel(pl ase indicate name If you have more than one residence connected of water syste below if ap icable—no to this well, check the Public/Community Water signature requi d , Cid 1-h o r 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: -...r;tg cLE C\Nu'EQS 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 F Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 4/27/2021 • Individual Water Well ❑ Water well report(attached to application). Depth ft. 0 Well capacity Test(attached to application) gpm 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://qis.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. ❑ 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: Environ. Health: .r1 - `D Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 • IMF 0 CL CD IY 011 WATER WELL REPORT Nonce Ef InT tent No. W218612 Original&l"copy-Ecology,2"c copy-owner,34 copy-driller s al ''t'i'Cos' 'r Unique Ecology Well ID Tag No. APN 966 Construction/Decommission("x"in circle) El Construction Water Right Permit No, G2-27822 H ❑ Decommission ORIGINAL INSTALLATION Notice Property Owner Name Three Fingers • pr /c, of Intent Number +'a `—( Well Street Address 781 April Lane O PROPOSED US m Domestic ❑ Industril ❑ Munici Industrial City Grapeview County Mason 0 DeWater ❑Irrigation ❑Test Well 0 Other C Location se 1/4-1/4 nw 1/4 Sec 23 Twn21n R02 t ❑ check Q TYPE OF WORK: Owner's numb r of well(if more than one) WWM 00. �+ m New well 0 Reconditioned Method:❑Dug 0 Bored 0 Driven (Lat/Long(s, r Lat Lat Min/SeC RI ❑Die ®Cable ❑Rotary ❑Jetted ( g Deg E DIMENSIONS: Diameter of well 8 inches,mined 140 .e. Still REQUIRED) Long Deg Long Min/Sec O Depth of completed well 140 ft 22123 T5 90162 CCONSTRUCTION DETAILS Tax Parcel No. Caches D Welded 8 " Diem from_+1 ft.to 130 ft.ft CD Installed: Liner installed " Diem.from ft.to CONSTRUCTION OR DECOMMISSION PROCEDURE ...CThreded " Diane from ft.to ft. r Formation: Describe by color,character,size ofmaterial and structure,and the kind and Perbrftiam: ❑Yes ®No nature of the material in each stratum penetrated,with at least one entry for each change of 0 Type of p..,for.tor used information. (USE ADDITIONAL SHEETS IF NECESSARY.) OSIZE of{serfs in.by in.and no.of party_ from ft to It Zf MATERIAL CI F TO r m 6 = Serena: 0 Yes ❑No ®K-Pac Location__12;1_---_ Gray Sandy Clay with Gravel RI - -Manufacturer's Name JohSson Brown sand&Gravel with water ''_m 6 27 RII Type Wre wrap Model No. Brown sandy Clay 32 +'' Digit. 7 Slot sue 40 from 130 ft.to 135 ft. R Dian7 Slot size 40 from 135--.-._-_ft to 140 ft. Gray Sand&Gravel wet/silty i 32 48 Gravd/Fiiter peeked:❑Yes l No ❑Size of graveVsand Gray day&sand with peat ^i lip 55 Q) Materials placed from ft to ft Brown sandy day f) 55 76 C ..Fr Surface Seal:(Yes ❑No To what depth? 20 R Silty blue day 0 r— 76 85 > Material used in seal_ Bentonite Blue silty sand with peat/wet L.' �5 90 C Did any strata contain unusable water? ❑Yes m No Gray silt bound sand&gravel with peat/wet. 'O 120 iType of water? Depth of strata Coarse sand&gravel water bearing 120 140 Method of sealing strata off PUMP. Manufacturer's Name Type H.P. OWATER LEVELS:Land-surface elevation above mean sea level ft. z Static level 58 ft.below top of well Date 06-14-06 Artesian pressure lbs.per square inch Datetit r VT Artesian water is controlled by - - • - ■y�l�s�j C K.•lfff ti— Q (cap,valve,ate.) 73 WELL TESTS: Drawdown is amount water level is lowered below static level 'nn�► Was a pump test made?0 Yes 0 No If yes,by whom? `1 fi06 1 f DI Yield: gtl./min,with ft.drawdown after hrs. Dia Q Yield: gal./min.with ft.drawdown after hrs. (tearr oF EcnioGv OYield: P.a1./min.with ft.drawdown aver his, rt l DRILLING(MR o Recovery data(time taken m zero when pump turned off)(water/evel measured from well i.{.I top to water level) Time Water Level Time Water Level Time Water Level all yr C Date of test _ EBailer test 40 _ gal./min.with 13 ft.drawdown after_2.5 tin a..a Airiest gal./rm..with stern set at__ n.for hrs. 1— RI Artesian flow _ ._ _ -_-. g.p.m Date_CL __-- Temperature of water Was a chemical analysis made? 0 Yes 0 No CI Start Date 06-01-06 Competed Date 06-14-06 CD WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all t Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. la Driller Cl Engineer CI Trainee Name t) Dwane H Kn naapp Drilling Company Knapp Drilling Driller/Engineer/Trainee Signature 1w PIA"t Kei-0-f Address 50 E lesaca Drive Driller or trainee License No._ 1706 City,Sato,Zip Shelton,Wa 98584 If TRAINEE, Contractor's Driler'a licensed No. Regime:ice No. KNAPPD195281 Date 06-30-06 Driller's Signature -- ECY 050-1-20(Rev 3/05) Ecology is ass Equal Opportunity Employer