HomeMy WebLinkAboutWAT2024-00053 - WAT Application - 9/25/2023 - Dx53
MASON COUNTY WAT
COMMUNITY DEVELOPMENT
eerma n L:unu amen emw�rc.namm�e
415 N 6-Street, Bldg 8,Sheton WA 98584,
Shelton:(360)427-9670 ext 400 J Belfair(360)2754467 ext 400 4 Elms:(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: ,rEPL oL Apf BI egX6yDate: "7 26 A023
Mailing Address: gyo -E• GFAAR SS 6E4iA.TR Phone: Uo - '73/ — 5c Fr
Parcel Number: 3 � no L'-Sd- 04 o07- E-A, 9HS2&
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit ( a2-&;L (-0o1)a
connections) ❑ Division of land:
Pit Individual water source (one connection), 1 of Parcels? SPL
FL Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
H 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 Sys m
Name of Water System:
Water Facility Inventory(WFI)Number:
(write"none for two-party)
❑ 1 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.
❑ 1 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.
1:\FH Forma\pinking W.W Revised 1/25/N118
Individual Water Well
Water well report(attached to application). Depth ft.
J� Well capacity Test(attached to application) 25 gpm 7 (_ 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 htto:dgis.co.masonma.us/olanning 14[M1501t=22[=
Water use or limitation recorded................................... N/A;Z Yeses_
Well Drilled ..........z f 2.'�/. O c O . f Dale 6- 2s z,o-mo
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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)
atisfactory 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.
u Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
pReviewees Signatures:
Environ. Health: .r'\III Date",
CSD Director: Date 2°f 2
Ff"Onpw wm WATER WELL REPORT - Ndiwd'dW„ 4u 0`tS.t l
DepamnM piEwbEy -IENy C
c t1Nro WELL!.DE
Seaw cop/-Own STATE OF WASNING'ION
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1* (se) STREET ADDRESS OF WELL:(Of"Peet GWFOW —
TAA KROEL NO.: n n n O Stg 'S -+ r(. OO^n
(0) PROPOSED Use: 5m.. U bNs m ❑ MMaIpM (RW NIEu W DECOMMOOMM•A060NAE DEEDANIT"
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ELY 056P20(R1IeB) 68W.TM TDD number k 13E01 RO]-SOM
NICHOLSON DRILLING INC.
PUMP TEST
NAME: Jeff Carey DATE June 6,2023
SITE: 72 E Island DR TIME
Shelton,WA 98584
WELL DEPTH 6 eat WELL DIAMETER 61 inches
PUMP MAKE Gfun PUMP MODEL 228QE74190
TANK MAKE I TANK MODEL
Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate
110" To Doom gpm to Down gpm to Down gpm
Water Water Water
_ 27. _ 0.0 25.0 40 38.5 11.0 25.0 660 0.0 _
?� 1 37.5 10.0 45 38.5 - 790
2 38.1 10.6 5o 38.5 11.0 780 0.0
3 38.1 10.6 60 38.5 11.0 25.0 840 0.0
4 38.1 10.6 70 0.0 900 0.0 "
5 38.1 10.0 80 0.0 960 0.0
6 38.1 10.0 25.0 90 0.0 1020 0.0
7 38.1 10.6 100 0.0 1080 0.0
8 38.0M0.8
120 0.0 1140 0.0
9 38.1160 0.0 1200 0.0
10 382180 0.0 1260 0.0
11 382210 0.0 1320 0.0
12 382 240 0.0 1380 0.0
13 38.3 25.0 270 00 1440 M0.0
14 38.4 300 0.0 1500 15 38.4 360 0.0 1560 20 38.5 420 0.0 1620 25 38.5 480 0.0 1680 30 38.5 54 00.0 1740 35 38.5 25.0 800 0.0 1800
R C VERY
Time Depth Draw Time Depth Draw Time Depth Draw
to Down to Down to Down
- -- Water Water Water - - -- -
1 30.4 2. 11 27.8 0.3 45 0.0
2 29.1 1.6 12 27.8 U. 50 0.0
3 28.2 0.7 13 27.6 0. 60 0.0
4 27.9 0.4 14 27.8 0. 70 0.0
5 27.9 0.4 15 27.8 0. 80 0.0
6 27.9 0.4 20 27.8 0. 90 0.0
7 27.9 0.4 25 0. 100 0.0
8 27.8 0. 30 0.0 120 0.0
9 27.8 0. 35 0. 150 0.
27.8 0. 40 0. 180 0.0
SIGNED BY: r
Chris Chilton-Service manager '
J t• SPECTRA Laboratories-Kilsap
. - Wrar.Narmma
COUFORM BACTERIA ANALYSIS FORM
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Contact Pemwe Nimmlaon D ng -
Day Phuna(3B0)878-0421 Zte,plant:
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SAMPLE INFORMATION
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Type of Sample(dmck only mm bm)
1.❑Routine OlstrlbWlon Semple(NP) 2.❑RepW 6mnple(.18ry
ChImalad:Y. D No❑ Bam&t@iMnsyYnmaueeLNuOne)
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LGround Welar Rule Saone Semple ——— ------
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❑Aaamvnmt(PR)
4•IA.blece wGWl Raw Source Water Sample(Enumeral m)
8
❑ E mF ❑Fecal vuree r.s_x._
6. Sampe CUmembebrmlametlmn Only:
t¢9US60NLY ,DRIMNIPl,�iWA't#RRE¢ULTS LAS:USEONLk +
❑UmeBeactory Total ColHorm Preeentand story
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❑ Semple Vobma ❑Omneged CoNelnrc ❑
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26276 Twelve Trees Ln NW She.C
Poulsbo,WA 98370
SPECTRA Laboratories - Kitsap (360)779.5141
...Where experience matters
IOC TEST PANEL
Complete or Selected Inorganics
System ID No: System Group Type: Private
Sample Number: 01042103 System Name: JefCamy
Sample Loartion: Wall Head COM43, Mason
Sampler. Josh Stour
SoruceNumbea(s): Sampler Phom No:
Sample purpose: Other Date Collected: 060/00073 II:30
Staple Compoeitmu: Single Source Dad,Received: 06107I202317:00
Sample Type: Drinking War Date Repeated: 6111
Niclwlsou DdlUg Inc. Nicholson Drilling Inc.
P.O.Box 123 P.O.Box 123
Port Orchard,WA 98366 Prat Orchard,WA 983"
WHY Anabde I Reedb I Oud. Udb SDRL POL I TrWer I MCL I Pxceed Metlwd lAjWystj Analyaie
MICIL I I Dab
0020 NMSI NO I - I milk 1 OS 1 0.0330 1 8 1 10 1 EPA300.0 1 NV 061080ni
NOTES:
TorsPomedon Include the ongtml lab number,sample number,and celtedon date of odglnel sample h older ad or sampler comments union.
SORL (State Detecdon Reporting Limit)The minimum reparable detection of an one"m eadebtshad"a department.
Trlggertevel: DOH ddnkirg water residence level.Systems with compounds detected at commutators In success of this level may be required to lake
additional samples or monger more frequently.Please mrdact yew DOH drinking water regional oaa M hnNer lMormadon.
MCL: (Madmum Contaminant Level)If the conteminant amount exceeds me MCL,posts,=00 your regtena DOH office d determine fefooup actions.
NA: (Not Matyzad)In the means;come,Indicates this compound was not included in me amen analysis.
NO: (Nat Detected)In Me reaulb abmn,indicates this compound was analyzed and not detected at a level greater than or equal to the SDRL.
<(0.00x): The compard was not detected In the cemply at or above Me concentretbn indcated(uaally the lab metitod reporting dmit).
"I milpgrems pa literorparls has minor
NTO: nephdomeac Wrbidiry units(a measure of wafer dadty).
pmhoskm: Micro ohms pa centmeter(a measure of the ability of Me water to areW electricity),One micro ohm per mutterer is equivalent to ae niao
slemen per centimeter(uSlon).
No edstlng tlgga a MCL value.
1: Secondary MCL(Established for a esthete purposes,not health based).
r
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