HomeMy WebLinkAboutWAT2024-00005 - WAT Application - 3/25/2024 WAT A= ODDOS
415 N.6' Street
MASON COUNTY Shelton,WA 98584
Shelton:3604 ,Ext.400
COMMUNITY SERVICES
Belfair:360.2754467275-4467,Ext.400
a�aann.14 ..., e 0, Elm.: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: Applicantl Parcel Identification
Name on Applicant. Co/t N� 1rf�n r1'L Date: 3'�S'7�I
Mailing Address: 53`, to.kc G.M.,.,. Phone: 360 .111.12
Parcel Number: L12333 ' 51- 01004
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 0 Building permit BLWZOA4-000a 1
nnections) ❑ Division of land:
Individual w er source(one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ 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.
❑ 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wam
1:\EH Forms\Drinking Water R.imd 4/2M021
Individual Water Well
p Water well report(attached to application). Depth 2fo3 ft.
Well capacity Test(attached to application) .? S gpm Oa 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.
.fS Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto Y(is co.mason.wa.us/olannino 14_15_18 22_
Water use or limitation recorded................................... N/A_ L Yesh_774��,
Well Drilled ............................................................... Date L 7/71 C/-t
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)
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:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reawn(s).
Reviewer's Signatures:
Environ. Health Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Corey Nightingale Well Tag#: BPF167
Site Address: 5932 N Lake Cushman Rd, Hoodsport Depth: 263'
Date of Test: 3/20/2024 Static: 54'
Pump Set: 240'
TIME GPM LEVEL RECOVERY
1 Min 7.5 57.2 TIME LEVEL
2 Min 7.5 59.6 1 Min 82.4
3 Min 7.5 61 2 Min 76.5
4 Min Z5 62 3 Min 73.7
5 Min 7.5 63 4 Min 71.2
6 Min Z5 63.7 5 Min 69.9
7 Min 7.5 64 6 Min 68.6
B Min 7.5 64A 7 Min 674
9 Min 7.5 64.9 8 Min 66.9
10 Min 10 65.1 9 Min 66.8
15 Min 10 71 10 Min 667
20 Min 10 73.5
25 Min 14 74.8
30 Min 14 812
35 Min 14 82.8
40 Min 14 844
45 Min 14 85.5
50 Min 14 86.3
55 in 14 87.2
1 Hr 14 88.6
1 Hr 10 Min 14 89.6
1 Hr 20 Min 1 14 1 90.6
Vanguard Lanoratory
2635 Parlumont Lane SW,Suite A
Olympia WA 98502
VM-MaD 360-967-70I0
COLIFORM BACTERIA ANALYSIS FORM
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