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HomeMy WebLinkAboutWAT2024-00002 - WAT Application - 1/2/2024 WAT ao4 - MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6th 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: Jon Sharp Date: 11a-I a,pa4 Mailing Address: 3531 W Shelton Valley Rd Phone: Parcel Number: 419022190021 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit '6() a;,4-' 03 connections) 0 Division of land: 0 Individual water source(one connection), #of Parcels? SPL O Well ❑ Boundary line adjustment O 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. 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. 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 1/25/2018 .) Individual Water Well / O Water well report(attached to application). Depth 600 ft. 9121/Z006 l7 Well capacity Test(attached to application) le 8•1 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). (/17-7?0' Z 1, Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 1,M 15I 16i J 22= Water use or limitation recorded N/A M Yes, I—I Well Drilled Date 1\2V \b ko 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 re .•urce regulations. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.S 4 I ination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements yy I"' apter 36.70A RCW. 0 E Unsatisfactory Determination: M �� Applicant's water supply does not appear adequate to meet the needs of its inten( � e for t offing O reason(s). SOU /1'47 Reviewer's Signatures: 4J4 Environ. Health: Date 3 / //ZC'Z '(. 2 of 2 CSD Director: Date 1 • 01 WATER WELL REPORT CURRENT Notice of Intent No. WE05289 „„ Original&1"copy—Ecology,2"copy—owner,3'copy—driller re i'o'c'r Unique Ecology Well ID Tag No. ALJ513 Construction/Decommission ("x"in circle) El Construction Water Right Permit No. EXEMPT WELL ❑ Decommission ORIGINAL INSTALLATION Notice Property Owner Name WILLIAM&JOYCE BROWN O, g of Intent Number r Well Street Address SHELTON VALLEY/CLOQUALLUM RD PROPOSED USE: m Domcstic 0 Industrial ❑ Municipal City SHELTON County MASON 0 DeWater ❑Irrigation ❑Test Well ❑Other Location NE 1/4-1/4 NW 1/4 Sec 2 Twn19N R4W E"t 0 check TYPE OF WORK: Owner's number of well(if more than one) q wm 0 one 0 New well ❑Reconditioned Method:❑Dug ❑Bored ❑Driven ElDeepened ❑cable .m Rotary In (Lat/LOnS Jetted Lat Deg Lat Min/Sec Still REQUIRED) DIMENSIONS: Diameter of well 6 inches,drilled 600 ft. Long Deg Long Min/Sec Depth of completed well 600 ft. CONSTRUCTION DETAILS TaX Parcel No.419022100010 Casing m Welded 6 " Diam.from+2 _ft.to 20 ft. Installed: ®Liner installed 4.5 " Diam.from 300 ft.to 600 ft. CONSTRUCTION OR DECOMMISSION PROCEDURE Threaded " Diam.from ft.to ft. Perforations: m Yes ❑No Formation: Describe by color,character,size of material and structure,and the kind and nature of the material in each stratum penetrated,with at least one entry for each change of ' Type of perforator used PRE-SLOTTED LINER (.020 SLOT) information. (USE ADDITIONAL SHEETS IF NECESSARY.) SIZE of perfs in.by in.and no.of perfs_from 300 ft.to 600 ft- MATERIAL FROM TO Screens: ❑Yes QI No ❑K-Pac Location BROWN ROTTEN BASALT 0 3 Manufacturer's Name GRAY BASALT 3 150 Type Model No. PURPLE BASALT 150 164 Diam. Slot size from ft.to ft. Diam. Slot size from ft.to ft. GRAY BASALT 164 195 Gravel/Filter packed:❑Yes m No ❑Size of gravel/sand BLACK BASALT 195 245 Materials placed from ft.to -ft. GRAY BASALT WITH QUARTZ 245 278 Surface Seal:©Yes ONo To what depth?18 ft. DARK GRAY BASALT WITH QUARTZ, 278 Material used in seal BENTONITE CHIPS FRACTURED 288 Did any strata contain unusable water? ❑Yes IZl No DARK GRAY BASALT 288 315 Type of water? Depth of strata GRAY BASALT WITH QUARTZ 315 365 Method of sealing strata off DARK GRAY BASALT 365 390 PUMP: Manufacturer's Name GRAY BASALT 390 410 Type: H.P. • GRAY FRACTURED BASALT WITH QUARTZ 410 418 WATER LEVELS: Land-surface elevation above mean sea level ft. GRAY BASALT 418 485 Static level 169 t ft.below top of well Date 9121/06 DARK GRAY BASALT,QUARTZ 465 491 Artesian pressure lbs.per square inch Date GRAYISH GREEN BASALT WITH QUARTZ, 491 Artesian water is controlled by WATER(1.5 GPM) 525 (cap,valve,etc.) GRAY BASALT 525 545 WELL TESTS: Drawdown is amount water level is lowered below static level GREEN BASALT,QUATRZ,WATER(4 GPM) 545 568 Was a pump test made?❑Yes 0 No If yes,by whom? Yield: gal./min.with ft.drawdown after hrs. RED BASALT,WATER(5 GPM) 568 584 Yield: galimin.with ______ft.drawdown after hrs. GRAY BASALT 584 600 Yield: gal./min.with ft.drawdown after hrs. Recovery data(time taken as zero when pump turned off)(water level measured from well top so water level) � '3 LE!� Time Water Level Time Water Level Time Water Level i [16�J� OCT 3-44906 Date of test `; YYrash rr Bailer test gelJmin.with ft.drawdown after hrs. TC�+��t��r j1+j s�µ(` Airtest 5 gal/min.with stem set at 595 ft.for 2 hrs. lJ t Cn�().l�co10 y Artesian flow g.p.m. Date Temperature of water Was a chemical analysis made? 0 Yes m No Start Date 9/19/06 Completed Date 9/21/06 I 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. O Driller❑Engineer OTrainee N ED NE SO Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature�f�?� Address PO BOX 1790 Driller or trainee license No. 1886 City,State,Zip SHELTON WA 98584 If TRAINEE, Contractor's Driller's Licensed No. Registration No. ARCADDI098K1 Date 9/22/06 Driller's Signature ECY 050-1-20(Rev 3/05) Ecology is an Equal Opportunity Employer. 1 i Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer : John Sharp Date of Test : 11/7/2017 Phone : 206-354-5346 Well Tag # : ALJ513 Well Site Address: 3531 W Shelton Valley Rd Depth : 600' Shelton, WA 98584 Static : 167.7' TIME GPM LEVEL RECOVERY 1 Min 9 173.9 *Began test with TIME LEVEL 2 Min 9 178.7 open discharge of 1 Min 371.8 3 Min 9 183.9 system* 2 Min 369.8 4 Min 9 187.1 3 Min 368.1 5 Min 9 191.3 4 Min 367 6 Min 9 195.3 5 Min 365.8 7 Min 9 199.3 6 Min 364.7 8 Min 9 203.3 7 Min 363.5 9 Min 9 207.3 8 Min 362.6 10 Min 9 210.9 9 Min 361.6 15 Min 9 229.6 10 Min 360.1 20 Min 9 244.7 11 Min 359.7 25 Min 9 259.7 12 Min 359 30 Min 8 _ Z 273.1 ' 13 Min 358.1 35 Min 8 • 285.9 14 Min 357.3 40 Min 8 • 298.1 15 Min 356.7 45 Min 8 • 309.4 50 Min 8 • 319.8 -2,0-o 55 Min 7.5 329.6 1 Hr 7.5 337.9 1Hr 10Min 7.5 352.6 1Hr20Min 7.5 368.1 1 Hr 30Min 7.5 368.1 C-0 J • . , Thurston County Environmental Health . 412 Lilly Rd NE 1 ��. , Olympia, WA 98506 ;�_ - 360-867-2631 THURSTON COUNTY """ COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County I • Collected 1 C. i / j L' I oCL:..21,y ' ❑AM n Month Day Year ( P J �r (.:�(- '' Type of Water System(check only one box) 0 Private Household ❑Group A ❑Group B ❑,Other •%C j ,:_,..- Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# • • System Name: i Contact Person: SG.tk, ,, /,,q ; t Day Phone:Phone:(. ,( ),O ;5./- 5<,trl G- _ Cell Phone:( ) E-mail:1-E-GO;r T STu F c 6. j ft f 3 L. Eve.Phone:( ) t Send results to:(Print full name,address and zip code or email addressi— i I L.i1 S/ f 0AI Vi - L i' 7 '-i L7;'{i WA qq �f,1/ SAMPLE INFORMATION Sample collected by(name): / // /A/1 0 1 Specific location or address where sample collected: Special instructions or comments: ,',5 3 ' w. 5 r-/ z_7 A' Vol, t.L KI I J.' Al ' rr 114 L rt-A l L 4/,4 •-'l/1/1 Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free Chlorinated:Yes No ' 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coli-GWR(A/P) ❑Fecal-Surface.Owl.springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No _ ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other / / 4.0 Sample Collected for Information Only Investigative Construction/Repairs / Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ❑'Satisfactory ❑E coil present No Coliform detected ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli 1100ml. 4 • Fecal Coliform /100m1 Enterococci /100 ml. Method Code:❑',SM 9223E ❑SM 9222D Date and Time R ived:(L 9 ❑SM 9215E ❑Enterolert® J I i- Oil. Date and Time Analyzed: 1 1 / I 1 Date Reported: f/I'r(12`1 a^ Sample Number(DOH number plus^bee digits) `/�� Lab Use Only: 0 Q ' 1