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HomeMy WebLinkAboutWAT2023-00292 - WAT Application - 10/16/2023 1 1 0 wAT2v2' - 00d h MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6th Street,Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Bellew:(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: Ait( �/�� Date: a esr 2- Mailing Address: TC(3c -243 3 Phone: 3c p ? by Z cf Parcel Number: 2_2( ILt, 41 9c3.0 2-c_ Type of Water System Reason for Application Public/Community Water System (2 or more Building permit—RIGI 2623 b t 4 connections) 0 Division of land: 0 Individual water source (one connection), #of Parcels? SPL 0 Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 Other(explain) 0 Replacement or Remodel(please indicate name If you have more than one residence connected to em e if applicable-no to this well, check the Public/Community Water signa re required) System box. Wei t i 0 C.. e ail PailP Part 2: Water Connection :r:: ' water Nf I• cj00Iet appropriate f connection b ' evaluf3Ie Public Water System / r - Name of Water System: Ld ct Cjpe ._L_ Water Facility Inventory(WFI)Number: ' onE (write"none"for two-party) YV F L ZO Z Z -COO l 1 I am the manager of this water system.The water system has been approved for 2 services. There are presently 0 connection(s)in use. This will be the I connection. 0 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:,EII Fonns\Drinking Water Re\ised 1/25,2018 Individual Water‘. q5 Water well report(attached to application). Depth L ft. .S./rZ I?GZ 1p Well capacity Test(attached to application) \-2,— gpm �8O6 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. y , 61 Satisfactory bacteriological test(attach to application). W(G(Wn 7Z. Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14f 151-1 161 )22E1 Water use or limitation recorded N/A 0 Yes r f?2O '(9L. Well Drilled Date 5l/y(z0 Z Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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) 3/ Satisfactory Determination: / This determination does not address adequacy of the distribution system,guarantee an adequat:supply of water indefinitely in the future,or guarantee compliance with all applicable WDOE water resou a,e -tions. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Det: - .:4k. Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. 36.70A RCW. A . Unsatisfactory Determination: F�,Q �r /f Applicant's water supply does not appear adequate to meet the needs of its intended u e�'OlpJ e folloWiwg0 2e reason(s). c`.0UN� /02,�j Reviewer's Signatures: (F(zov(u✓q N,,764, 4�y�gCr Environ. Health: Date 2 • 2°'2 CSD Director: Date WATER WELL REPORT t,en_ DE"";a e N 0 Notice of Intern No.WE42666 ECOLOGY Unique Ecology Well ID lag No.BNA109 Type of Work: :.ate of vsaei+ine toe, • Coatructan Site Welt Name(if mote than one well I: Decommission==> Original installation NOI No Water Right Klink/Certificate No. Proposed Uses X Domestic ❑Industrial Cl Municipal Properly Owner Name Nick Reynolds U Dewalcring U Irrigation U Test Well U Other Well Street Addrlxs 141 E Wild Grape Way Conslrucdaa Type: Method: !l New well O Ahestion 0 driven .7 Jetted M Cable Tool City Grapeview County Mason 0 Deepening C Orher ❑Dug An- Mud-Rotary lax Parcel No.22114-14-00010 Dimemkns: Diameter of boring 0 M.,to 196 2 Was a variance approved for this well? ❑Yea 0 No— --- - Depth orcompkted well 795 fl. Construction Details: Wall If yes.what was the variance for? Casing Lino Dimmer I-ruin to 'thickness Steel PVC Welded Thread • ( 0 8 in. +2 190 1l4 in. La] I 0 :f I ❑ Location(see instructions on page 21: ©WWM or❑FWM O I O in. _ _ in. ❑ I ❑ ❑ I ❑ SE V..'/.ofthe NE '/4;Sccuon 14 Township 21N Range 2W O I ❑ in. in. ❑ I O O I rl I ❑ In. in. fl i 7 fl t [] Latitude(Example:47.12345) Longitude(Example:-120.12345) Perforaeenf: 0 Yes J No Type of perforator used ------- iMder's I.og/Construetioo or Decommission Procedure Nu.of pctf<ratiuro below perforatues In.by in. Formation:Describe by color,character.size of material and structure.and the kind and Perforated from_fl.to ft.below ground surface• nature of the material in each layer penetrated.with at kart one entry Wench change of Screens: XI Yes 7 No NI K-Packer may Depth 166 n information. Use additional sheets if necessary_ Manufacturer's Name Mel Madams Works Material From To Type Staines& Marl Nu. Diameter S in. Slot size20 in.from 190 f.to 195 fl. Top Soil 0 2 Diameter_in. Slot sir_ in.from_O.to fl. Brown till 2 25 SeadIFiNR pack:0 Yes F.No Sere of Blue Clay Layered wl Peat.Gravel,8 Water 25 155 Peek materiel`n. Blue Gray Sand&Water 155 175 Materials placed from ft to*n. Brown Silt Bound Gravel 8 Water 175 189 Surface Seat Yes C No To whet depth?25 R. Sand&Gravel,Water 189 195 Matcnal used in seal Remain Did any strata contain unusable water:' U Yes M --- Type of wafer! Depth of straw Method of sealing smite MT ---- P usp: Manufacturers Name GrundfoS Type.10S10 D.P. 1 Pulp intake depth:180_it Designed flow rate 12 gpm - Water Lerch: Land-surface elevation above mean sea level_ft. Stick-up of top of well casing_ ft.above ground surface Static water level_ it.below top of sell casing Date Artesian pressure bs.per square inch Date Artesian water is controlled by (cap,valve.etc 1 Well Tents: Was a pumping test performed?rl No fl Yes t • by whom? Yield_gin with ft.drawdown after_ha. Yield—gpm with ft.drawdown after hrs Yield_spin with_it.drawdur n after_hta. Recovery date(tine zero when pumps turned off-water level measured from well top to water knell Time Water Level Time Water Level Time Water Level Date of pumping test Bader tea 18 gpm wilt 7 ft.drawdown after2 hrs. Air two_gpm with stem set at_A.for_has. Date atl2121 Artesian flow_gpot I Temperature of water F Was a chemical analysts made" Cl Yes l'J No Start Date 04il21 Completed Date 05/12/21 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 arc true to my best knowledge and belief. ❑a Driller 0 Trainee 0 PE- t Nae Michael Davis Drilling Company Davis DriNing Signature Address 340 NE Davis Farm Rd License No.0797 City,State,lip Belfair.WA.98528 iF TRATNEE:Sponsors License No. Contractor's Sponsor'sSignature Registmt ion No.DAVISDI1100A Date05114/21 FCl'050.1.20(Rev fog'19)11 you need this dufumrni in an alternate lnrntal.plduaecall the Water Resources Program at 3M1-407.6872 Persons with&army has tan full 711 Jar Washington Relay.Service. Person*with o petal disuhilin trot cull R77-833-63i1. { 1786 SE Mile Hill I' Port Orchrard,WA .J SPECTRA Laboratories - Kitsap 96366 —Arm aperture(Miners COLIFORM BACTERIA ANALYSIS FORM 4ato Sample Collected lime Sample County Collected r`'} .Month Day Veer Type of Water System(check only one box) ❑Group A ❑Group B Cllhert i'`,Q{"'e_ • Group Aand Group B Systems—Provide from Water Facilities Inventory(WFI): ID# r� t System Name: N I r`�/ I ./oy h old S tp Contact Person:• vf- goy holds i_ Day Phone:( ) Cell Phone:( ) Email: r Send results to:(Print hip name,address and zip code or e-mail) • SAMPLE INFORMATION Sample collected by(name): Specific location where sample collected: Special instructions or comments: • • lips of Semple(select aNy one type of swifts From types 1 through 5 below) 1.❑Routine Distribution Sample(AlP) 2.❑ Repeat Sample(Alp) Chlorinated:Yes No (from distribution system after unsat.routine) Unsatisfactory routine lab number: Chlorine Residual:Total__Free_ 3.Ground Water Rule Source Sample — —— Unsatisfactory routine collect date: • • S I I Chlorinated:Yes___No ❑Triggered(Ai?) Chlorine Residual:Total Free___ ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) I $ I ❑E.co/i 0 Fecal Filtered Yes Na 5..Sample Collected far Information Only: LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY ❑Unsatisfactory Total Coliform Present and ler4 Satisfactory 0 Ecoli present ❑Ecoli absent Bacterial Density Results:Total Collfonn mpn 11OOm1. E.coP mpnJ100m1. Fecal Collforrn du /100ml. HPC 11 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container 0 DaittopRremn IV Cr Lab Reference Number t3 L1 1 -CI L/ Receipt Temp C•: method Code: SM822311 or SM9222D Dole Reported to DOH Lab Use Only — DOH Lab-Sample 225- 233-"i DOHNun#331.319(MbrEn O&17)./.rou reed doll rubka0min an sterge lerOreset de90.410127 trOOYNTYa l sill. This end a urpubrrailmr we se a* WeilokmalosNalthoeseler. 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