HomeMy WebLinkAboutWAT2024-00275 - WAT Application - 7/9/2024 WAT A0
MASON COUNTY
COMMUNITY DEVELOPMENT
PnmeKlsdree o, l ,Bulldlry,PlawiN
415 N 6a'Street,Bldg 8, Shelton WA 985a4,
Shelton:(360)427-9670 ext 400 4 Belfair: (360)275-0467 ext 400 . Elms..(360)482-5269 ext 400
3 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: Phil and Donna Angelillo Date: Z o 2
Mailing Address: 247 SE Weston Rd Shelton Phone: C i 1 759 - q%�Z
Parcel Number: 42135-50-00045
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit 160 g62y- 008 cZd
connections) ❑ Division of land:
El Individual water source(one connection), #of Parcels? SPL
0 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)
❑ 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 ymm.co.mason.wa.us.
J:\EHFomskDrvMngWatv Revisal 1/25/20B
J
Individual Water Well
Water well report(attached to application). Depth 1 7f ft. 3(/ 4/Z/7s7
Well capacity Test(attached to application) (0' S gpm T r 1 o gpd. �It}n/7oLy
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 whits.co.mason.wa.us/ tannin top 15Q t6p 22t]
Water use or limitation recorded................................... /A�Ves_�
Well Drilled ............................................................... Dale
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 8DO 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 W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6 68040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination: ^�
Applicant's water supply does not appear adequate to meet the needs of its intended use fa the foll
reason(s).
Nqe,. ✓//i
Reviewer's Signatures: >>c�NNIy Zf1p? ��
Environ. Health: 1-- Date FN
lq/
CSD Director: Date 2
y
Notice of Intent to Construct a Notice Number
Water Well WE56165
This form and required fees MUST BE RECEIVED by the Department
ECOLOGY
of Ecology 72 HOURS BEFORE you construct a well.
1.Property Owner
Name
Philip And Donna Angelillo
Mailing Address City State Zip Code
PO Box 1790 Shelton WA 985"
2.Consulting Firm(lt applicable)
Business Name
Mailing Address City State Zip Code
Email Address Phone Number
3.Well Site Location
County Name Tax Parcel Number
Mason 421355OW045
street Clear Lake Rd City Shelton state
A Zip code 98584
Township Range Section '/.(within 180 acres) '/.-Y. (within 40 acres) NW
21N 4W 35 SW
Latitude Degrees Longitude Degrees
4.Project Details
Estimated Start Data 7/17/2024 Project Name No.of Homes 0
Well use: Domestic(Single) Work Type: New water Right Permit: Not Required
S.Driller Details
Professional Name[Architect I License Number
Engineer I Surveyor](IF applicable)
Drilling Company Name Phone Number
ARCADIA DRILLING INC (360)426�395
Licensed Driller Name Driller License Number
ROGERAY PHYTHI 2053
Comments
r
mary
ount due for wells with casing diameter less than 12': $200.00ment to:Department of Ecology Cashiering Unit,P.O.Box 47611,Olympia WA 98504-7611line at https//appswr ecology wegov/wellconstruction/Wells/NoticeORMentPavmentReciuest.aspxus Date Confirmation I Cash Journal Number 4/17/2024 8:23:01 AM 24041744322700
�a
JIJZ 3 2024
RF�FIVFD
WATER WELL REPORT DEPARTMENT Of Noticeof Nlenl Na WE581M
ECOLOGY Unique Ecology Well MTag No. BPF141
ryre�nYns: slabofwamngtoD Sile Wdl Neme(if more thanom wslp'.
A <m,
❑ 11..u`ma.. O UigMl ilmelleticn NOl No. Water Right PamiWeitifeme No.
Pwlmr.11- Doamic ❑hioavkl ❑m—pul Plmerry 0.Name Ri' ntlD Arm III
U D.womdeg 0 initiation ❑T.We l 0 we, Well Street Address Clear Lake Rd
.—fflnan Type: Medved:
Nnr well ❑ANnnon ❑Onwn ❑lead ❑Cebk Tml City SICIIUa County M89M
❑lio,no' ❑Omm ❑Dns W Av- 0 Mud-Rou y Tu Ppmel No. 4213&5400045
IXmemlom: IAamew ofkonnp 6 4,b175 n. WuevmimNe approved fmthis wslll ❑Yes BNo
MMh of.nmplend wen 175 R.
Cen[nuenanoemik: will IfYn,Mfiel was the VViance fOR
cuing Lim, Dii— Fmm to ThkJxu 9x1 PVC WeHetl lNod
p ❑ 9 in 0 170 .25 in. 01 1 ❑ M 1 ❑ Lmahm(amiM=iiuuom,,g<2): f3WWM«0EWM
❑ ❑ =n 0 1 0 0 1 0 NN/ /.Rofthu sw Ye:3 hoe 35 Towm m Rip 21N Rpe 4W
❑ 1 ❑ e. ❑ 1 0 0 1 ❑ letilude(Eumple''47,12345)47.263979
❑ 1 ❑ in in. ❑ ❑ ❑ ❑
Longitude(Example-120.12345) .123.182408 '..
PeA—fl— ❑Ym �No TypeofpubalnuN DrIIkrS Lag/Copetrvcllax ar Deeommlaloa Protedert
No.alperfoyiam_ Sveofps6reExu_in tN_n Fxontioo:0.xMe by roles,cRuemm.tix ofmlmel and muclue.aM l6e Mdnd
"fomtitl In it belawmowd�ur� anina ofRw mwnnii.exh lqv paevaxd.wRb in lout one a4y fa mh oMye rf li
&Wane: MYm ❑No OWPSYmb Dwili-81 R iofxmemn. llx Wilioml al¢eu irx[wary.
Alanufa.—,.Nux McYMeallble Wmke Malonal Fmm To
Type Stainless elulbe Mulct No. Brwvn lea amld mm level D 22
No— 5_ SMebe 018 to flown 170 ft. 175 A
Momne,_ swinut .mmu _R.to_a SlolY quentil.lunge 22 87
MNM1Cdaled Mld IaYN a 87 L15
S.,upiu-w=k:OYea ®No sioz.flx W Fount!meBun
tn. ul_in ion u M 115 133
Meleluls ryued Nw_Rw fl. RmzM mWtl-0d0retl revel,wa in 133 175
Sint-Snl: OYn ❑No Towhu&0? lB R.
Mauna usM in xal B¢Dl to Elll
Didanysuai mainwlmbl—ineoi ❑Ye ONo
Typeofwntee? Deptin.r.M.
M.".fa u..rwm.R
Pomp: M—uon ni i Nit:nc TM:
H.P_ PwpinWedW,_R. Eagxdnpwinno_gpm
W.rce Lerela: IW+xfe[eekwun chow m.nv kxl yet R.
Swk-u .lo,elfwell Wring 15 fl.ebsepoud nntni
An i—poo no 11e RRebwl nodillouilg 0.re 1/1224
Anxianpw'aaux_10..perryum iul: D.I._
Aneaian wx<ru[mlmlkd by (W.rdw.el[) '
Win Tnn:
W........ng len{erprmeY/MN. ❑Yx0 b,w ?
Y,_pn wnh_A Jaw .fier lea
Yield_gpm wiN_n.dmedown after_lea.
Yield_W:nvilh_n.Mwdo oioftl_M.
mm
Recovery d[u(lime<zw when p:ary is mmNOT-wnr YM�mwamM Wong xell
opno
T—
W weWe
Time n
.ar level Time Wum L.vel Tis W.wlewl
Dal ofpwwiglea
tnu_mm witll_R.
Auto.
M wdown nfle[ M
Air lax 20 ppawim axmwnl lW fl.6r 1 M. Deb 711224
Anesw Nw_9qn
Tempexrweofw.le, 0 =F wmecM—I.wlyauomkl ❑Ym MN- I MS.aWejI-0VA24I�pW1WI7I1212024
4
WELL CONKTRUMiffi CERTIFICATION: I cansaucmd aIINm amept lesponsibiliry(orconsllllnian ofthiswell,elW ib romplruce with pll Washington cell
colnlmetion stnMa ds.Materials uud ald the infamatim reported above art true to ney best knoWledge not belief
Driller❑Trainee❑PE-Prim Josh Kce Dill C Arratlle Drilkrg Irk
Si //_ Address PO Buz 1T90
Li No 2874 /L Cty Sl Zip Shellan WA 985M
IF TRAINEE.Spmsm' Lieve.No Corueeho,i
Spola=.'s Simmte. Retibionam No.ARCADDI098KI Wm 7MM4
ECY050.1-20(Rev08l18) /1)uo nmd Nis dmumem in an alxmanf Fpleaw mll dm Wamr RemurcesProgram�r 368-48Z68I7. I,
Pn iviMX ringb millllfor Wasldngma Relay Service. PenmowirhaWp hMmbiliom mIl8DAiJfi341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Philip&Donna Angelillo Well Tag p: BPF141
Site Address: Clear Lake Road, Shelton Depth: 175'
Date of Test: 7/17/2024 Static: 119.5'
Pump Set: 160'
TIME GPM LEVEL RECOVERY
1 Min 3.8 119.7 TIME LEVEL
2 Min 3.8 119.8 1 in 119.5
4 Min 3.8 119.8 ✓UC Z3
5 Min 6.25 119.8 RF�Fi 1G
6 Min 6.25 120 VFW
7 Min 6.25 120
8 Min 6.25 120
9 Min 6.25 120
10 Min 10.5 120
15 Min 10.5 1204.
20 Min 10.5 1 120.4
25 Min 10.5 120.4
30 Min 10.5 1204
35 Min 10.5 120.4
40 Min 10.5 1204.
45 Min 10.5 120.4
50 Min 10.5 120A
55 Min 10.5 120.4
1 Hr 10.5 120A
1 Hr 10 Min 10.5 1204.
V anguaru Lanoratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
VMORo�aD 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM ✓U� �1�
nw,I aTb Calpr>eE Tura Sample Cwary
07/17/2024 ', :w MASON Ff`�?�1G
tfPa d Web Syebn ItMM aNr on pa)
❑Ct A ❑Omwo ■Coro_
Ii1WP A am CG BSyw -Pmetla pun We FacKe k."(M)
IDM
SrnemN m PHILIP ANGELILLO
G Peron Aro"a Dr OV.htc
DAY Ppwe(3 I416.3M Cep;*..I 1
Emai Eve.Pnate:l I
pdnalYb'.ternb�ap6aaarC:a mar aamap
ateegyrre W�irra mm An0 Knn@vuaariwp mn
SAMPLE INFORMATION
sw p�m�a pr I ez SHAD
Speefic bcapm where sack m9w.'bb Epeclel4eev:bora of comments:
XBPF141 Clear Lake Road Shelton
TWaa &W*heap rob Mb"of woo k"" a1t .*5heUw)
1.pRmein UWAwpm SwpY(W) T.I] RpWSwP*WP)
ChwMw Yea—RD._ "'a'=vA"""rrrlem aax wa�wu.al
IlMamia:ksJ roupne ab number
CAlaine Ras4wl ioW_Ftte_
3 Groww WalwrFam w SRepte llmwwlmYmNneaAkttaate
Cwb o%d-Yee_N�
0 TIVIleea lAr) CM R%d.:.Tal Free_
❑Asawmenl(AV)
1 Surhoe or GFn Rewaourp W+br SOttpM lEnym znotil
❑E caN ❑Fe¢
5 ■wo fu'b:ha b knormaion a^h'.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
O thuWA4ceory Teal Cofiium Pt ntw �75MNficbry
❑EpiPpetR ❑Eolmsem
8"ft Dempy Ruwft Taal Coelam 1IW EL 0000,
FeoalCgiFxm AM HK nm.
RpIu~Sorge Rpopet: ❑TNTC ❑Sampb Nc at
❑ SB�Tkr Vnxrc ❑DamapepCmlelw ❑
,� 5; �p uo rrrew\a
SM9223B
I$o l@pdmamlAln us ore oar
ooa LdPSYrelee
2a5-