HomeMy WebLinkAboutWAT2024-00268 - WAT Application - 6/18/2024 WAT AQ;L4 - 009(ed
415 N.6ie Str
MASON COUNTY SheftM WA 98594
COMMUNITY SERVICES Shettao:360427-9670,Ext.400
Eelfe¢360-275-067,Ext.400
aaavyv�omy,em o.memm wwmc�mw�hxwm Elmo:360482-520.Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fuse 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 Identification1 _
Name on Applicant: V7I� r�6CA .. Date:
Mailing Address: I2 OZ 122,K C Phone: `31F0 — 531 - ISM ?Zs
Paree4Nanrber. M-1Ak gp r W p- c7lb }�
P I yps of Watery System 00 o Reason for Application
❑ Public/Community Water System(2 or more Q& Building permit15LD;Z Oq4 0011�0
connections) ❑ Division of land:
1} Individual water source(one connection), #of Parcels? SPL
t4- Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) El Other(explain)
❑ Replacement or Remodel(please indicate name
/f 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.
❑ 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.tnason.wa.us.
19eH Fame\Dni*i,W.Wr Rn,1,w 414 20 18
Group B Water Systems
i
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Water well report(attached to application). Depth 125. 7 ft.
Well capacity Test(attached to application) IL S opm ?' 4OU apd.
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 within last year(attach to application).
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,Tide 6,Chapter 6.68.040-Determination of
Adequacy for Building Pennits are satisfied. Additional Growth Management requirements may $y. Chapter
36.70A RCW. h.•q
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended for the folbwing
reason(s).
OU CO6 �®Reviewer's Signatures: / F6y�P 14jy
Environ. Health: Dale
This form may be scanned and available for public view at www.masoncountywa.eoy
Page 2 oR
6 "bZoZq- 00-7g
WATER WELL REPORT iffi DEPARTMENT OF Notla ofloWnt No.WE59993
ECOLOGY Unique Ecology Well ID Tag No.BOP-041
Type of Work: State of Washington
® Coosmmtim Si a Well Nam lif mart Than oa wd0:
❑ Decommiaim o OdgHW waMlwiw NOR W Water Right Pernd/Ccrufeste No.
Pmpmea um: ®Dpmmx ❑EWmiel ❑aamdpd property O vnerNsnc Dennis 5 Darlene$9"
❑Dewatemg ❑bdpdm ❑Tm Well ❑Olhm
Well Seat Address 160 NE Mehaaam Cf
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*Ne-
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Disstloan Diamdeofb-dng e—m.,min ft Wasav mccappmvcdfor MiswdI? CYO ONO
Deplhofemopldedweli1257 ft,
CwftsMNS Daaik: Well If ye,what was the vsimae for?
Cuing Lind Dmmeu From To vuelmms Sled PYC WeNad T waa,
IS ❑ 4—in. N_2 1zD.z _in. H 1 ❑ ❑ 1 ❑ Location(Me inalrvcWfu on page 2): 0WWM or❑EWM
❑ ❑ _In. _in. ❑ I ❑ ❑ i ❑ KY.'Aofthe aaf.'A;Seim2Tawmhip= RW,2W
❑ ❑ _m. _ _in. ❑ ❑ ❑ I ❑
❑ ❑ _m. _ —ro. ❑ 1 ❑ ❑ ❑ Lastude(Exampk..47.12MS)4749170
Longimde(Exmnple:.120,12345)-122 93235
PeMnWs: ❑Yd ONo Typ ofpefpamruW
No.afper[aadm_ Svc apelkrad _in,by_M, DrilledLog/Contraction or Deeommiarms Procedure
Pmfmadfim_Rm_fl.below grmmd wdm Fomom.Oe Wbyeoim,diaader,aveofmatmalmdamxuue,and Mekindmd
o&FOo.-e mnedd m evA layer mnennd,with at Imie m<mry fm emh rbanye of
Sraema: ®Yea ON. ❑K-ParkaO DIM—A. wfmmvnm. uu ddidaW sheds if acuaary.
Mswt twi," a Material From To
Type Model No.Desn-ETN@ Sloi.16_in.fmm 3203_flm1257 fl LI bravo cobbles gravel sand clayey sip 0 3
. .
t>;mndd_ Skiartc_in.from _n.l- fl. U greyish brown glacial fit 3 m
SsefFem pack:❑vd ON. Sim ofpaa maomel_is. Brownish gray cobbles gravel sand clayey SIR 34 70
Maeiala plaed fiwn_an_fl. Brownish gray gravel sand clayey SO oat 70 105
Tan grovel SS M sit water 105 125
Sur4a Seal: 0 Y. ❑No TO w aepm?10 fl. Lt grayish brawn gravel Saint!clabat, 01 125 125
Mandaloect,..d BENTONITECHIPS
Didmysnamn unwiahlewate? ❑Yd ONO
Type-fwwefr DeRnbafatrm
MCNad of mhng rtala off
Prig: Mmufumrd'a Name Ty
HP._ PunPlniakedvph:_e. Denasd Sowaae:_aps
Wum Levey: Land-aurfam elevation above mem mlewl_ft.
Stick-up-flop of well wing'01 ft above grdud avdae
Snticwmdlevd8l ft Wowtwofwellaring Date t0/3W2a24
Artesia p..lb,W aquas imb Dan
An-ee weer is mtrdled by (cm.vdw,en.)
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wu a Pumping wV pm &17 ®N- ❑vea C by"-?
Yield_g en wish_fl,cirawdown after_bn.
Vi-m _gpn wish_ft dnwm-eau_bn.
Yield_gpn with_ft draw&- Age_In.
Rm San(time-um ohm poop is N,r,off woe level meuuni fmm well
sepN.)evd)
Time W.Level Time Warr Levd Time W.Lew]
Owe dPwngnH nl —
Beilertea_Nmw _Rdnvdwm,flu_8n.
"Net 29 gpm wiM nda xl a]2g fl.foci bn. 0.1c 109w2024
Arnim Oow_Wm
Tdnpuwreofwater_•F WaacGmimlmdysu mtle? OYw ONO Sron Den,10/2W2024 CompletM Due 1
WELL CONSTRUCTION CCRTIFTCATION: I cawward and/or acceP rtspm3ilby for conwaion of Nis well,aM its compluna wiih all Washigba wall
comwmbv ssMards.Mataids used atM the ivrowubn rtponed above eR we ro mY hest ktwwledge end belkf.
®Driller❑Trainee❑PE-Print Name Mark Wess Wllbe Commny RICHARDSON WELL DRILLING
Soared.. dam// Address PO BOX 44427
License No.2432 City Stan,ZipTACOMA WA 96446
IF TRAINEE:Sponsor's Licens M. Conhseter's
sm.s Signions, Reei ustion No RICHAW'3210B Data 10131/2024
ECY050-1-20(Rev09/18) ll)'owneedrhudocvmeminanalkm ielor .p/eattmNeh Wamr Nerour<as Programat36 407b872.
Person rnrh Moring lma mn all li(jor N'nhington Relay Servia. Prime with a.rpcech dNabiloycan mII877.8334341.
RICHARDSON WELL DRILLING
Aquifer Test Data
Well]D# BOP041 Owner: Dennis Stickle
Site Address: 160 NE Mahogany Ct.
Pumping Well Parcel#: 223097700260
Pump On 1111824 11:45 Pump Off 11/1824 12:45
Date Time Date Time
Reference Static Level 76.50 Fast Pump Size 1hpl0gpm
Recorded By Time Water Levels
Date Clock Elapsed Time Reading In Depth To Drawdown COMMENTS
Since Start G m Water
Josh 11/182024 11:45 0:00 6.5 76.50 0.00
11:47 0:02 6.5 76.90 0.40
11.49 0:04 6.5 77.00 0.50
11:51 0106 6.5 77.20 0.70
11:53 0:08 6.5 77.20 0.70
11:55 0:10 6.5 77.20 0.70
12:00 015 14 78.40 1.90
12:05 0:20 14 78.50 2.00
1210 0:25 14 1 78.50 2.00
12:15 0:30 18 79.10 2.60
12:20 0:35 18 79.30 2.80
12:25 0:40 18 79.30 2.80
1230 045 18 79.30 2.80
1235 0:50 18 79.30 2.80
12:40 0:55 18 79.30 2.80
12:45 1:00 18 79.30 2.80
RECOVERY 1246 1:01 76.90 040
1247 1:02 76.10 -0.40
12:48 1:03 75.00 -1.50
1249 1:04 74.40 -2.10
12:50 1:05 74.00 -2.50
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YATER
ja MANAGEMENT !i315 Soth St. E.
l aroma. WA 98404
LABORATORIES 1Nc (253)531-3121
lqw
NitratdNitrite
Report of Analysis
Date Collected 11-18-2024 System Group Type (circle one) A B mer
Water System ID Number. NIA System Name: Dennis Stickle
Lab Number/Sample Number: 089109634 County: Mason
Sample Location: 160 NE Mahogany Ct, Belfair-Wellhead Source Number(s): (list all sources if blended or composited)
Sample Purpose. (check appropriate box) Date Received 11.191
RC-Routine/Compliance(satisfies monitoring requirements) Date Analyzed: 11-19-2024
❑ C-Confirmation(confirmation of chemical result)' Date Reported: 11-26-2024
❑ I -Investigative(does not satisfy monitoring requirements) Supervisor Initials.
® O-Other(specify-does not satisfy monitoring requirements)
Sample Composition: (check appropriate box) Sample Type (check one) ® Pre-treatment/Untreated(Raw)
❑ S-Single Source Post-treatment(Finished)
❑ B- Blended (list source numbers in"Source Number field) Unknown or Other
❑ C-Composite(list source numbers in"Source Number field) Sample Collected by Josh
13 D- Distribution Sample Phone Number:253-537-7332
Send Report&Bill to. Richardson Well Drilling Comments:
PO Box 44427
Tacoma WA 9844E
ANALYTICAL RESULTS
DOH# ANALYTE OATH RESULTS SDRL TRIGGER MCL UNITS EXCEEDS METHOD/
QUALIFIER MCL? IN
0020 Nitrate a5 N 1 o /
TOTES:
Confirmation: Include the original lab number, sample number, and collection date of original sample in either comment section.
-No exisiting value.
rNALYTE: The name of an analyte being tested for.
)ATA QUALIFIER: A symbol or letter to denote additional information about the result
)OH#: Department assigned analyte number.
ACEED MCL: (Maximum Contamination Level) Marked if the contaminant amount exceeds the MCL under chapters 246-290
no 246-291 WAC. Please contact the department's drinking water regional office in your area to determine follow-up actions.
AETHODIINrnALS: Analytical method used. /Initials of the analyst that performed the analysis.
ag/L: milligrams per liter or parts per million.
tESULT: The laboratory reported result.
;DRL: (State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the Department
f Health
RIGGER: The department's drinking water response level. Systems with contaminants detected at concentrations in excess of
its level may be required to take additional samples or monitor more frequently. Please contact the department's drinking water
egional office in your area for further information.
AS COMMENTS: