HomeMy WebLinkAboutWAT Application - 10/16/2024 WAT -
MASON COUNTY 12Ep�aC�M6NT
COMMUNTTYDEVELOPMENT �ME
verm�cns:i:u«e gym,emla�re,vunma
415 N b-Street,Bldg B,Shelton WA 99594,
Shehon:(350)427-9570 em 400 A BegFir(( 275-4h-767 797 tt 400 a Elme:(360)4s2-5269 ext 400
Application for Determination of Water Adequacy
r3.
ructions
Complete Part 1. No determination can be made until Part 1 is fully cemoleled
Complete only the portion of Part 2 applying o the type of water connection utilized.
Submit completed application,with any required attachments for review.
, Ana roved buildin site Ian must accompany this a lication.
Part 1: Applicant/ Parcel Identification /
Date:
Name on Applicant: n a
Mailing Address: IQ`f01' Phone: �/eV7- 744 - 318 Z
Parcel Number
�,r�Xo� 2 P�77
Type of Water System Reason for Application
Building permit
❑ PubliciCommunity Water System (2 or more ❑ Division of land:
connections)
Individual water source(one connection), #of Parcels? SPL
,�!:Well ❑ Boundary line adjustment
❑ Springlsurfam water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
you ha of water system below if applicable—no
If ve more than one residence connected signature required)
to this well, check the PublirJCommuniry Water 9
System box.
Part 2: Water Connection Information
Complete the section appropriate for he 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 figrnnectionservices.
There are presently connection(s)in use.This will be the
rade or
ge the use of an existing
ll be to
❑ �nntectionaon this systeml(i.1e.r recreational to full.This connection tilme). Please ndicate onn he follow ng line the na ure
of this change:
theis water system
is able an or aln g to Asset by state and locml o this sa)reg cotronctron(s)without exce Ing
the
sys
em
Signature of Water System Manager
Date
This form may be scanned and available for public view at www co__ mason`wrzp-
1:\Ea Fwrtv\Drintiny wafer
Individual Water Well
❑ Water well report(attached to application). Depth
ft.
❑ Well capacity Test(attached to application)
gPm apd.
The well driller often performs all capacity tests at the time the well is constructed. Results from
these tests are noted on the water well rlicant or f thlts e water well report does not these tests will be chaa ve a capacity test,
well report cannot be located by the d. If the water
applicant
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 W RIA hdo llois w mason wit us/blanning 14015=16C:3 220
Water use or limitation recorded....................
N/AJ=Yeses
Well Drilled ...............................................
Date
Individual SpringlSarla ce Water
r[031
mit(attach to application)
disinfection
son to believe that this water source can provide at least 800 gallons per day; and/orater at a rate of 2 gallons per minute based on the following observations.
Date
Author of Statement
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
F36.70A
tory Determination:
determination does not address adequacy of the distribution system,guarantee an adequate supply of
"ter indefinitely in the nded approval future,
or Titlerequarairements of Sanitary Ctee compliance with lode,Tl ati�bit.Chapter 6.66.04o De ermination of
y for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
CW. lef
factory Determination:ts water supply does not appear adequate to meet the needs of i[s intended use for the following).
Reviewer's Signatures:
OxLDilm Ip}_ �
Environ. Health: Date z orz
DSAG�
CSD Director
Water Well Report For An Existing Well
Your well must be properly tagged prior to submitting this form.
Asterisks(')indicate required fields.Mail completed a original
WA ton to:
DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olymp
-7600
ECOLOGY
¢uu of walMnoan
Use this to rm ff an original Water Well Report was never filed or Is missing from ECebgy reco
'Unique Ecology Well ID Tag Number. BOL 635
-Current use
®Domestic Olntlustrial OMunidDM ODewater -Water Right: ❑Vas('rf yes,attach a coPY) ®No
Qlmga6on OTest Well ❑Other.
'Property Owner Name: Ken S Tina slater
Dimensions
Diameter of well 6 In. 'Well Street Address: 1860 E Island Lake r
Depth of completed wee 103 R(if known) -City. Shelton 'County: Mason---
construction Details -Site Well ID:
Unerinstalled: ❑Yes DENO OUnkmMvh Liner -Tax Parcel Number: 320085W2077
Type: OPVC OSksel OConcrete Liner
OUnknown ❑Other._ 'Date Well Constructed: Unknown
Perforations 'Location(Township,Range,Section)
Dyes ONO OUrlknown
Size of perforations_in.by_lm __R An accurate location of your well is very important. The
Number of perforations_from_ft to Section,Township,Range,and Ya,%ran be found On your
tax parcel legal description or through your county
Screens assessors office.
®Yes ONO OUnknown
Type: ®Stainless Steel OPVC E10 d to�� R Township 20 Range 03 ❑MM OF®WWM
Diameter • Slot Size_ Section 06 NE 114-1/4 SW 1/4
GraveVFllter Pack
Oyes wo Ounknown Comments:
Materials pieced from_ft.to__ft Unable to determine surface seal due to concrete floor.
Surface Seal Conshucton date unknown.
Oyes If known,to what depth_ft.
ONO ®Unknown
Materials used if known:
❑Bentonite OCement
Pump
Dyes ONO OURkrwwn Latitude/Longitude
Type Rome POD— (Decimal Degrees recorded to 5 decimal places)
Water Levels Latitude(Example 47.12345)
Land-surface elevation above mean sea level—ft. 47.24825
Casing stick-up 11 above/beloW land surface
Static Level 6 tl.b.kw toP Of casing Date measured:10121, Longitude(Example 118.12345)
Artesian Preaaara_Ibs.per square In. Date measured:_
-1231087
Well head has cap- ❑Yes ONO Shut off valve?OYes ONO Additional Information(If available,please attach)
Well Tests: ❑Location marked on topographic map
Drawdown Is amount water level is lowered below stetic level ❑Local on marked on air photo
Was a pump test made?®Yes(attach copy)ONO O Unknown
Yield: 11 gaVmin.with 10 ft Orawdown after 6 hrs. D Consutant well report
-Certification:The Information reported above is true to the best of my knowledge and belief.
®Consulting Finn ❑Driller ❑Engineef ❑Property Owner
Hacket Com ' Moarke S San,,Pump and Drilling
AnthonyName: Address of person completing this form:
License Number: 1162 NW State Avenue
Si net Chehalls,WA 98=
S 10- 30-701 Cg , Slate ZI
ECYm0. V(0 f)016)wi Impaired lieeix18 . teas W I O,.Relay BSery N 7j j or r�A s w d W�hdimblility m ya la a gr-933434a1 360407-
MOERKE & SONS PUMP & DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360)748 3805
PUMP TEST
KEN &TINA SLATER 1/21/2024
1940 E ISLAND LAKE DR
SHELTON, WA 98584
WELL SITE ADDRESS: 1960 E ISLAND LAKE DR,SHEL ON Set At:
Pump Make & Model: 1/2 HP rump
Sounder Make& Model:
Make&Model: Measured in: GALLONS
INM UTES GALLONS METER LEVEL TO
PER MINUTE READING WATER OTE
0 37966.5 32
1 13.5 37980 38'
2 12.5 37992.5 40'
3 12.5 38005 41'
4 12.5 38017.5
5 12.5 38030 41'8"
6 12.5 38042.5 41'10"
7 12.5 38055 42'
6 12 38067 42'3°
9 13 38080 424"
10 12 38092 42'8"
15 12,6 38155 411
20 12.4 38217 43'
1 13 38230 43
2 13 38243 43'
3 11 38254 43'
4 12 38266 43'
5 11 38277 43'
6 11 38288 43'
7 11 38299 43'
6 11 38310 43'
9 11 38321 43'
10 11 38332 43'
15 9.4 38385 43'
20 11 38440 43'
25 11 38495 43'
30 11 28550 43'
35 11 38605 43'
40 11.4 38662 43'
,6 38720 43'
45 11
50 11.4 jot , , 43'
55 11.2 38833 43'
60 11 38888 43'
41'
5 40'
10 38'
15 36'
20
25
32'
30
SIGNATURE yf G� �N
MO KE AND SONS PUMP AND DRILL G
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