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HomeMy WebLinkAboutWAT2019-00114 - WAT Application - 4/23/2019 (2) ‘ I- 20(9 -OO I IL-1 • pS0NC0% --PCuL Public - Health Always working for a safer t healthier Mason County 415 N 6'h 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 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 system utilized. 3. Submit completed application, with attachments to the health department for review. Part 1: Applicant/ Parcel Identification Name on Applicant: NV\I (- n (-loon \f>YitY'l�(��nrr►��11�""Yltc Date: 2.3 •2tf Mailing Address: 2cl N MII A V60 VekG C VIISPhone:: 3lpt` '740 • �3 Parcel Number:: 12 nl9 33•cln©1n Type of Water System Reason for Application ❑ Public/Community Water System (2 or more lY Building permit connections) 0 Division of land: d Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water ❑ Other(explain) 0 Other (explain) 0 Replacement (please indicate name of water If you have more than one residence connected system below if applicable—no signature to this well, check the Public/Community Water required) System box. Part 2: Water System Information Complete the section appropriate for the type of water system 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. 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 J: till Fonns Drinking VA;ucr Revised 12,1 1; Page I of 2 This form may be scanned and available for public view on the Mason County Web site. Individual Water Well Water well report (attached to application). Depth L`.jb ft. ❑ 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). 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 Departmental Use Only: Do not write below this line. Part 3: Mason County Public Health Evaluation I Satisfactory Determination: Applicant's water supply does appear adequate to meet the needs of its intended use. 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. 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 Signature: Date J:\EI I Forms\Drinking Water Revised /1'15 Patc ail This form may be scanned and available for public view on the Mason County Web site. WATER WELL REPORT ta..i DEPARTMENT OF NoticeoflntentNo. WE32230 ECOLOGY Unique Ecology Well ID Tag No. BLH214 Type of Work: WI State of Washington O Construction Site Well Name(if more than one well): 0 Decommission => Onginal installation NOI No. Water Right Permit/Certificate No. Proposed Use: L•3 Domestic LI Industrial ❑Municipal Property Owner Name Sharon and Ervin Taylor ❑Dcwatering II Irrigation ❑Test Well ❑Other Well Street Address E Harsline Island Road S Construction Type: Method: PI New well ❑Alteration 0 Driven ['Idled 0 Cable Tool City Shelton County Mason ❑Deepening f 1 Other 0 Dug O Air- ❑Mud-Rotary 'fax Parcel No. 120193390010 Dimensions: Diameter of boring 6 in.,to 256 R. Was a variance approved for this well? 0 Yes CI No Depth of completed well 256 R. If yes,what was the variance for? Construction Details: Wall Casing liner Diameter From To Thickness Steel PVC Welded Thread --- C 1 L1 6 in. 0 252 .250 in. 0 I 0 0 I ❑ location(see instructions on page 2): IR WWM or El 13WM ❑ 1 ❑ in. in. ❑ I El DICI SW Y.-V of the SW 'Y.;Section 19 Township 20N Range 1W 0 1 0 in. _ _ in. ❑ I ❑ U I 0 El I El in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ latitude(Example:47.12345) 47.201838 Longitude(Example:-120.12345) -122.863741 Perforations: ❑Yes ®No Type of perforator used_. - No.of perforations- _ Size ofperforatio s in.by in. Driller's Log/Construction or Decommission Procedure Perforated from fi.to R.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes ❑No 2 K-Packer Depth 250 O. information. the additional sheets if necessary. • Manufacturer's Name Alloy Machine Works Type Stainless Slotted Model No. Material Front To Diameter 5" Slot size.016 in.from 251 fi.to 256 e. Brown silty sand,gravel,loose 0 12 Diameter Slot size in.from ft.to_ ft. Brown sand,gravel with clay binder 12 27 Sand/Filter pack:0 Yes O No Size of pack material in. Brown medium sand,gravel 27 53 Materials placed from ft.to ft. Multi-colored gravel,medium-coarse brown sand 53 84 - - Medium to coarse brown sand,some gravel 84 198 Surface Seal: E Yes El No To what dope,? 19 ft. Multi-colored gravel,medium brown sand,loose 198 210 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes F]No Multi-colored gravel,brown sand,peat 210 213 Type of water? Depth of strata Brown fine sand,wet,silty 213 224 Method of sealing strata off Brown fine sand,some gravel 224 226 Gray fine sand 226 227 Pump: Manufacturer's Name I YPe Dark brown peat,wood 227 234 I l.P. Pump intake depth: ft. Designed flow rate: gpm Multi-colored gravel,fine to medium brown 234 Water Levels: land-surface elevation above mean sea level_210 ft. sand,water 245 Stick-up of top of well casing 2 ft.above ground surface Medium brown sand,water 245 253 Static water level 193 ft.below top of well casing Date 4/15/2019 Artesian pressure lbs.per square inch Date Multi-colored gravel,medium brown sand,water 253 256 Artesian water is controlled by (cap,valve,etc.) __. Well Tests: Was a planning test perfonmed? El No ❑Yes r > by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. - Yield gpm with R.drawdown after Inn. Recovery data(time-zero when pump is turned off-water level measured from well top to water level) Time Water t.evel Time Water level Time \\'atcr Level f --- Date of pumping test__-_ ___ -Bailer test gpm with ft.drawdown after_hrs. Air test 20 gprn with stem set at 240 ft.for 1 Ins. - Date 4/15/2019 Artesian flow gpm --- Temperature of water 50 °F Was a chemical analysis made? ❑Yes El No Start Date 4/12/2019 Completed Date 4/15/2019 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 I 1 Trainee❑PE-Print Name Jo oepp Drilling Company Arcadia Drilling Inc. Signature ! Address PO Box 1790 I,icense No. 2874 / �� City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. !!! Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 4/15/2019 F.CY 050-1-20(Rev 09/18) If you need this document in an alternate formal,please call the IValer Resources Program al 360-407-6872. Persons with hearing loss can call 711 for lVa.shington Relay Service. Persons with a speech disability can call 877-833-6341. • I `W Z I-E R MANAGEMENT Ala LABORATORIES Irrc:_ = 1516 80th St E,Tacoma,WA 98404 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 5 1 to i r 9 DAM m ksok) Month Day Year Type of Water System(check only one box) 0 Group A ❑Group B "Other ( Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# — — t 1ST v System Names'' OA) 7A()() z5L"j) Contact Person: Day Phone: ^ - Cell Phone:( ) Email: Eve.Phone:( Send results to.(P Int lull name.address and zip code) Pc 3o X SAMPLE INFORMATION Sample ed b (name): Specific location where sample collected: Special instructions or comments: WW Iq Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(AIP) 2.0 Repeat Sample(MP) Chlorinated:Yes No (from distribution system after unsal.routine) Unsatisfactory routine lab number: Chlorine Residual:Total__Free • __ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S I I I I Chlorinated:Yes No ❑Triggered(AIP) Chlorine Residual:Total Free ❑Assessment (AIP) 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.coil ❑Fecal rdteted Yes No 5.❑Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present 0 E.coli absent Bacterial Density Results:Total Coliform I100m1. E.coli I100m1. Fecal Coliform 1100m1. HPC /1 ml. 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