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HomeMy WebLinkAboutWAT2024-00297 - WAT Application - 8/7/2024 WAT -DD/ LL MASON COUNTY COMMUNITY DEVELOPMENT Permit Mslslance C Pff,,aummM Planning 415 N 6-Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 0 Bellair(360)275-4467 ext 400 0 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: RACHEL CLARK Date: Mailing Address: 5115 ANDREW ST. SE LACEY, 1Phone: 775.720.7767 Parcel Number: 2,J21 7&2VW0 Type of Water System Reason for Application /Vy� ❑ Public/Community Water System(2 or more El Building permit 8020a OG I 4 - VL connections) ❑ Division of land: El Individual water source(one connection), #of Parcels? SPL El 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 PublicrCommunity 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. ❑ 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 This form may be scanned and available for public view at www.co.mason.wa.us. 196n Fame\peiating Warn RevisW 1/25/2018 Individual Water Well Water well report(attached to application). Depth —" I 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. YY� Satisfactory bacteriological test(attach to application). / Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planning 14Q 15=1f=]220 Water use or limitation recorded................................... N/AJ=Yeses Well Drilled ............................................................... Date 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) �„nSatisfactory 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 6.68.040-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 for the following reason(s). 2 y/V�pReviewer's Signatures: Environ. Health:--y�` l Date CSD Director: Date 'of' WATER WELL REPORT S DEPARTMENT OF Nnicenfintwt No. VJE55884 ECOLOGY Uni,.. Dingy Well o T,No. BPF200 Type or Wort some of Wasting'. ID trim"". Sim Well Name(if.Oleo one well). ❑ OmoomioimO O:igmalinsulla:io.NO1 No. Water Right PermiVCMlficeR No. Proposed Um: R Dame", ❑Ldoornal ❑M::nkiwl P-Pertly Owner N. Rarfwl Clark ❑Dewmarn, o bn'Hniaa ❑ [",Wall ❑Ddkr Well Siren Addrm 121 E PasseRe Vlew Rd Cgmm—it Type: MedOn:od: City Shelton Cow Mason R Noswall ODraw . ❑N, Dial ❑Cabo Tool tY tY ❑IXepatins ❑other ❑Dos O Ali, ❑MudRary Tax Parcel No 22127-76-00070 Dimensions: Diememofbod.e 6 in.,m 154 R. Was a variance approved fen Nis wall? 0Yes 2No Depthofcon,leodwell 154 a. Camkeadmi smash: Was If Yea,what was thevnm.a fofs Cein Unew Di macr Fmm To Thickness glad FVC wemW Threw p ❑ e is 0 1Bp.E .25 in. © 1 ❑ R 1 ❑ Iucetim(see irlsmmtiomwpage]): 11WWMcFOEWM ❑ ❑ n. 0 1 ❑ ❑ 1 ❑ SE -%wfthe SE K;Scoim 2] Township 21N Rm�e 2W ❑ 1 ❑ —� _ _ — Y. _in ❑ 1 ❑ ❑ 1 ❑ ❑ 1 ❑ tens u ❑ 1 ❑ ❑ 1 ❑ latitude(Example:41.12345) 47.27573N Longitde(Eaample:420.12345) An.913N)W PerReafions: ❑Yes ON. TyPeafmrfixamrmM DrI11erY LoWConnruaflon or Decommission Procedure Nn.niperfarariom_ 5:reofpnfonliom_iby_ Formation cri[e by robr,chvcler,mime of.uleneleMsvuca:e,mdn:e loud vW PerfomM sons_R.m_d below,p:eardwoae amem.flhe now 4io molt lays penetrated,with m law am enoy for coh cheese of &ream: 0. Y. ❑No OK-Peck' G Depls 148 R. inRereama Ua sddilioal show ifmassoy. Modmmmel4Noe Alloy Macldne Works Material Frans To Type Wire-www Model No. Diemem 5_ SW sim 015 i&Ran 140 R.w 101 R. Snown silly flue send and grannal 0 8 Diomm_ s W size_i Fmm _R.a_E Brown fine gravelly sand,siltbound a 13 Brown fine sand silt 13 16 SeoNFJk.pml❑Yen salon siuofpot mwrkl_io. Gray peatysilt 16 24 Mamia6 plead Rom_R.m_R. Gray sticky dW 24 39 SVNee Seal: Ill mat ON. Towbl deptM1? 19 R. Gm ravel sand cl 39 M Masai,road monamaeal Bervo-wribl to Chip Utl coy shW conuio unumbkwrYrl ❑Yes iJ No BrUWTli9h gray CIO ,peat 44 47 T,c.fwm0 Degh ofww Gray hard clay 47 SR Mmixot.faalmgstraYolr Only sigy day E8 65 Gray clay.veins of grawel 85 1 BB Pomp: ManohcMei m None Type: Gool(Irle 10 Coarse saki,fine to medium arity BE H P._ Nan,intrim&Plb:_R. Desilpwd Row ask-._®m m oel,hem ,siftou d 81 Water Lewla: Lnod-ImGce elevetionebove me Ise level In fins Gray ravel silt 81 85 Stick-upafmpafwell1.u11_8 R.eboweeroudmwam Gray fine granneiry sandy silt 86 117 Slarwnmkvel 104.5 R below lop ofwell.sine One 8=4 Anafen pa eme_Ins,par aRasse imh Dam Grayfine to medium sand end ravel,sifbound. 117 Annamor oru canmmd by (.A wall,re) maist 136 Fine to medium nooltFcoloretl sit sand.grannal, 1W Wen Tmm 141 Whoa mmgrW tin wrimmd? RNo 0Ym b by whom' Wet Wed_Awo wan_ens m.wmwaaRor_m. Brown Brie send.trim to medium multla0bratl 141 Yield_Van wish_R.downtown and_bra round granel.witm tearring 161 Yield_epos wins_R.dmwmwo eRa_Ins. Blsck medium sit re"Al Shoals.fight.Ware. 154 155 nawery dn.Prow=ram when an,is mmrd oR-wem t wl mawad gown was 'Pmwarelma0 Time Wewtewl Time Water Level Tito W.Level Oak ofpurtpi,g l<v Bailer,._®m wbh_L Nwdowoaam_Ma l An. 20 gpmwina wmsm.t 120 R.Pon 1 Ins. r Dar, M4 Anau.Raw_ppm J TemPmeveofwea 52 =F wmeolmmialemlohnnde? ❑Y., RNo gimp pose 811124 Cuaripleted Date Bf2J24 WELL CONSTRUCTION CERTIFICATION: 1 calslmcmd orld/a except rapwsibility fa cossuswlim ofNu well,and its compliance with ell WmRinglon wMl cawmnion smMads.Mnmids used Mtd the infmmniw reported above aR we m my best Imou4wge and belief. ❑Driller 0 Trainee O PE-PrortNateneCor,Johnshorni Drill2 Co aparly Arcadia Drilling Inc. Silpwurc _ Address PO Box 1790 Liwac Na. 3441T City,Share,2'p Shelton WA 98584 IFTRAINEE:Spwww's Licwse No 205 C rsraetor's S,.W,a Signature i Regionalist,No.ARCADDIOBBKI Doe 8t2/24 ECY050.1-20(Rev 11g) Ijyounadrhisdocumeminanallemarrjor f.pleaeclltho Wamr Remmces Progmmm36 O7-M72. Persons with hearing Ion tin call llljor Washington Relay Service. Persons with as arech diaaDliny tin ca11817433-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98504 Customer: Rachel Clark Well Tag#: BPF200 Site Address: 121 E Passage View Rd, Shelton Depth: 154' Date of Test: 8/9/2024 Static: 101.5' Pump Set: 140' TIME GPM LEVEL RECOVERY 1 Min 6 102 TIME LEVEL 2 Min 6 102 1 Min 102.8 3 Min 6 102.1 2 Min 102.7 4 Min 6 102.1 3 Min 102.3 5 Min 10 102.1 4 Min 102.3 6 Min 10 102.7 5 Min 102.2 7 Min 10 102.7 8 Min 10 102.7 9 Min 1 10 102.8 10 Min 15 102.8 15 Min 15 103.5 20 Min 15 103.6 25 Min 15 103.8 30 Min 15 103.9 35 Min 15 103.9 40 Min 15 103.95 45 Min 15 103.95 M 15 104 15 104.1 5 104 15 104 v rm angua uaw.,ury 2635 Parkmont LAne SW, Suite A Olympia WA 98502 vA.ggAFo 360-967.7010 COLIFORM BACTERIA ANALYSIS FORM Gee Smrpa Coasted rmsw"cobecled Canty 08/0912024 , o ow MASON Ib9i dl Y. �•~ Type Of Wa anrm(men.mM one om) ❑Cn A ❑Gm B ■are, GMW A r4 Gmg8 Syarm-Pmd*hmn Warr Notes Imen"(WFl): syaam Nra: RACHEL CLARK CwW Perm-A=dlo aNey.Inc Dn ftre:(3W 14263395 La Ptmna l 1 E.1: Ero Phorc.( ) aee,�i h 1Rire N tine,Ner55 3a ip woe o emery e,a,eOrcasaman0-mnaao pm,ga�wo mm SAMPLE#FORMATION SaMW caecrd by'na ) SHAD Speak bca Ymme Bangle wpecbd Specialaeaumvsarcmnnnna. 121 E Passage View Rd,Shelton Typo Smga(eaW mW m ryp dWee eom types i h%O 5 bn) 1 Olt a Gaelaudoe Sample WP) 2 ❑ Repr swepa(ARl Ch�WYes No Pmn dafiWemsKem iwt uva mAnel UneaEa+aUm/,uIWM bD numder Cnbnnp Re5i0ua,Taal_Free- 3 Ground Wear We Sa oSemple VaaaaWy,ouam mlledah. L=L.yJ —7�— Chlonnad Ya_No_ ❑Thagemdl�) ChbnMRaNuI:TaYI__FRe_ ❑AasessmeM(A?) a Sump or GWt Aaw Saum Wear SenpNlEnum»mn) I _ 1 , I ❑ECW ❑Fatal ,meYw_w_ 5 �S aw fNbac�a Flwmela My: LAB USE ONLY DRNKL40 WATER RESULTS LAB USE ONLY ❑UnsrNiac"TOW Caacm Peso ad �J SralsWo,y ❑Ems plasm+ ❑EcoaWnl Bww,WDwmayRmaa ToICoaonn I1Wml ECM naORA Fern CCronn 1100M NPC N IN. RplammM Sample RetoWd: ❑TNTC ❑SrlwInc old ❑ senw Vn — ❑Dmapdemrlw ❑ A2. ., 5 AAW+ pc' 8.0 1YiAve0* SM9223B CaeRe, a00R uouaaN o uesa pr 285-