HomeMy WebLinkAboutWAT Application - 9/27/2023 �.y'L9Nb�
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415 N.61°Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelon:360427-9670,Ext.400
Belfatr:360-2754467,Ext.400
emianwvrimrerewmm.,ui a®im�mn..nn�+� El.:360482-5269,En 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: Applicant/ Parcel Identification
Name on Applicant: FUTugrHc)MrSrgVICFS Date 9/27/23
Mailing Address: Po Rnv ogna r:1r.Hngwog,wn oaagq Phone: aa11_90111_o777
Parcel Number: IaANU-13-000 )
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 04 Building permit -61h;lLD.-3- OIIq$
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
bit Well ❑ Boundary line adjustment
❑ Spring/surtaca water❑ Other(explain) ❑ Other(explain)
)I 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wams.
1'TH Forms\DdnFng Wa Revised 4/4/2918
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm Cpd.
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 http//ais.co.mason.wa.us/planning 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source win 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 detemrination 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
38.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reasonts).
Reviewer's Signatures:
Environ. Health: Date
This form may be scomlited and available for public view at www co mason wa us.
Page 2 of 2
NICHOLSON DRILLING INC.
PUMP TEST
NAME: Darren Cribbs DATE I September 18,2D23
SITE: 372 Frog Pone Lane TIME
Belfair,WA 98528
WELL DEPTH Feet WELL DIAMETER inches
PUMP MAKE PUMP MODEL
TANK MAKE TANK MODEL
Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate
,maw. To Down gpm to Down gpm to Down gpm
Water Water Water
Static 35.2 0.0 40 42.8 7.8 18.7 060 0.0
1 41.1 5.9 45 42.8 7.6 720 0.0
2 42.4 72 50 42.8 7.8 780 0.0
3 42.8 7.8 60 42.8 7.6 840 0.0
4 42.8 7.8 70 0A 900 0.0
5 42.8 7.6 18.7 80 0.0 960 0.0
6 42.8 7.8 90 0.0 1020 0.0
7 42.8 7.8 100 D.01 1080 0.0
8 42.8 7.61 12D 0.01 1140 0.0
9 42.8 7.6 150 0.0 1200 0.0
10 42.8 7.6 18.7 180 0.0 1280 0.0
11 42.8 7.6 210 0.0 1320 0.0
12 42.8 7.6 240 0.0 1380 0.0
13 42.8 7.8 270 0.0 1440 0.0
14 42.8 7.8 300 0.0 1500 0.0
15 42.8 7.8 360 0.0 1560 0.0
20 42.8 7.618.7 420 0.0 162D 0.0
25 42.8 7.8 480 0.0 1880 0.0
30 42.8 7.8 540 0.0 1740 0.0
35 42.6 7.8 600 0.0 1800 1 0011
RECOVERY
Time Depth Draw Time Depth Draw T6ne Depth Draw
to Down to Down to Down
Water Water Water
1 38.7 3.5 11 0.0 45 0.0
2 36.0 D. 12 0.0 5o 0.
3 352 0. 13 0.0 80 0.
4 0.0 14 0.0 70 0.
5 0.0 15 0.11 80 0.
6 0.0 20 0.0 90 0.0
7 0.0 25 0.0 too 0.0
8 0.0 30 0. 120 0.0
9 0.0 1 35 0. 150 0.0
10 0.0 40 0. 180 0.0
SIGNED BY:
Alan Myelte-Pump Supervisor
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