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HomeMy WebLinkAboutWAT Application - 1/15/2025 WAT MASON COUNT„�(,iRONMENr 415 N.,W 9584 11 ' Shelton,WA 9.400 Public Health & Human Services rl9helron:760-4�tA67o,Bxt."` HEALTH F�tffI'�b Application for Determination of Water Adequab6N 15 2025 Instructions 615 W. Alder Street 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 of Applicant WO law, �Anna Lo��S Date: l/ 1.�( ZS Mailing Address: PO Sex 1107y Albn .W& 9y5-##Phone: Zj9 71,3 93 Parcel Number: 1 ZZ7 _43 —000/0 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more ❑ Building permit connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Sprin /surface water ❑ Other(explain) 1,8 Other(explain) rT V ty We/1- Tttro PA Replacement please indicate name If you have more than one residence connected of water systemm be l6w ow i If applicable—no to this well, check the Public/Community Water signature required) System box. ,rlL�a,� <j -00015G Part 2: Water Connection Information FJ �,,,rU P v"— 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 hull 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountima.goy JSEH F.mo prinking Wmm Revixd 05/097024 Page I art Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well See a Adr� Uiell Water well report(attached to application). Depth 7Z fZ Well capacity Test(attached to application) 3 ❑pm ' 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. _ see p aCO�S�wA s�L �/'%l�''i' '� ���f'/'f �' ry g w M I `s(y*(ani �o application). s Satisfacto bacteriological test wit n as 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,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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). BViewer's Signatures. Environ. Health: �O Date This form may be scanned and available for public view at www.masoncoun�aaov Page 2 of 2 WATER WELL REPORT NCURRENT odmofIn Y15786e 190"96wb" ` f� Nola o{]ntmtNa F ZI F- ell Odgmal R lu copy Emlogy,god copy-owmer,3rd copy-drilkt Unique Ecology We11IDTag No. A G N 1 8 4 Cp{d{i{itlionrDecomn[Svuto(-s'in rinds) WmuRigM PamitNo. C)CousMVAon 0 Dceommssion ORIGINAL CONMUCfION Notice of Intent Number pMpMy Owner Name Nielsen Brothers PROPOSED USE: ®Domestic 0Iadiuoia1 ❑Mvoi ilul Well SDmes AMMLI G r e D e v l e v Loop ( Lot A ) ❑UeWater ❑1s ipfin ❑Test WeU OOther G r e D e v i e v (:mmy: me s a n VT City EOF WORK: Owoels oumW of well lif trine I6an note Ls_d! S V 5 E 2 9 2 2 N 1 4 Ems' ciroL ®New Well ❑Reoundinmd Mtdldd'[]Dug ❑Borrd ❑M,ma L9Cetion.1 4-114 _IId Su_ Tway R� m one ❑Deepened DCable ©utary ❑leud LIMng; wWM got 1st Deg _ La{h8o/See _— DA1ENSlONS: Dimekrofwell_�ocbm.ddlld 74 R �{nRED) Wig Deg— Lppg}vDN$es _ pep0°tc4mWned well 72 it lax Parted No. 12229-43-00010 cONsTRUcfiONDETAns O Cuing OWddd 6 Diam from at Rm�fs_R CONSTRUCTION OR DECOMMISSION PROCEDURE Inemlled: ouncrmstailed __ Dim. Rlo__ft Fotmatio¢Daeribe by mim.dmnckvsit of material andsaumuc.and the _ pima from Rm_ft kind and moue ofthe material in men smmm pme d,With uleut one Totaled may for etch change of infmmatioo.Iodiute all water eocoumeted. Perfoem"mc DYet Ff No (USE ADDITIONALSHEETS IF NECESSARY.) Type of pmromm tad - MATERIAL FROM TO SIZE of pern_h.by_iaand a a ofperfe_Rom_R m__R Brovn fine to medi Um 0 Saeern: (3 Yen 0 No 0 K-Pac Location 65 send e n tl ifr... ve l 35 Mavufactanes Name d h Brovn medium to coarse 35 Type S l o t t e d Model Nu Dim " Slot Sin . 014 On1_67 ftm 72 R. sand end revel -noiat Diam. Slot Sit Ro^ R.to R. Brovn medium to coarse 62 GnreMherpacked: ❑Yu UNo ❑Stu of ImvWsutd send , gr eve I , rounded Mavrials scd from Rio fL e a t e r 7 2 Swf.ce Stab ®Yes ❑No Towbddgtb? 90 it Br ovn silt eley, veter 72 74 Mamdalsud ki soi Bentonite Did any mun—We unusable weer? QYes 0No Type of warn,,? Depth of sum- Method of amfio{mein oR PUMP. Mamfuooees Name Type: X.P. {PATER LEVELS; Imdamfact elevation above mass sin level 1 5 f{ Sods levtl 8 Rbebw top of well Oak in-t0-nt Artesian Pressure—des.pu moue mcb Date Artesian watm u cmgolid by 1 .valve.Nc. WE"TESTS: Dnwdown is ammot wum level is lowmed now.antic keel. Wuapumpummude?0Ya ON. Ifyu,bywbomn Yield;_JdJW°.with fLdnwdownaber hn. Yidd_.YIJmi°.-uh R dmwdowo aM Env Yield:_Pllmin.well ftdnwdown atkr W. Recovery elan(time ,,m as uro whin puny rimed a.RNwmer level mearu.ed/min m11 top m.11keel) Time Ware,level Trim Watt keel Tmr Water Level MI of test ith__R.dnwdown afm�lrs Ad1e . mo, wn I 0 sal/min.wdm vein stt v_�_ Dan Atmnv Dow a s . Sun Dam 10-9-01 Compleld pakl0-t0-01 Tenlpcmmcof wader A9 Wu•cM_WWaWYds made? ❑Ya MN. WELL CONSTRUCTION CERTinCATIM 1 constnlctd anNor accept MPonsibildy for conanttenoa of this well,and"'compliance with all Wubington well construction standards.Materials used and the infommrim reposed above ate true to my bett kooWldge and belief. d Driller ❑EalPmm ❑TWnce Name(Poop Ro9e y Phythian Drilfing Company A d ' a Dr ' I l ins Inc . Dnller/Fng'im a trrwnm Sig az >__ Address 1 7 0 SE Walker Park Road Driller ce Trainee License No. 2 0 3 Ciry,S=,Zip c WA g R 5 R a Corl='S ARCADD109SKI 10-10' If trsism,Licensed drWer's Registration No Sig"Mce end Llcm n no. F<otogy is m Equal Oppotuniry Emplga. ECY USa1-20(Re. gt,gaoa5-000s� COOLWATER DRILLING, INC. 10921 HOLLY RD NW RECEIVED BREMERTON, WA 98312 JAN 15 2025 360-830-9005 1111. Alder Street COOLWDI941QM ENVF4ONMENTAL HEII,LTH CUSTOMER NAME DATE: 15 January 2025 La Loftls CUSTOMER ADDRESS 6980 E Gra eview LP RD TIME STATIC GPM TIME STATIC GPM 8 05 12 18 120 25 18 10 15 18 135 25 18 15 18 18 150 25 18 20 22 18 165 25 18 25 25 18 180 25 18 30 25 18 205 25 18 45 25 18 220 25 18 60 25 18 235 25 18 75 25 18 240 25 18 90 125 1IS 105 125 1 18 RECOVERY STATIC RECOVERY STATIC TIME 25 TIME 05 12 30 10 8 45 15 60 20 75 25 90 T.1.NW � T,pa is N' smc ' SPECTRA LAbomtorin, Kimp � 983TB J3t0y779_11011_ COLWORM BACTERIA_ANALYSIS FORM i pab SanpIF CWKsb -T-"ime&mqe i Caunry - - OI IDZI Zo25' cpo�xlm Hasp,--_, � Iryad Wafer SYabm ldNd d9l OnebaJ /�i✓iC� ❑&r A OGWB OO 'WU ..pa�S, :GroYpnwa GroupBRysbrms-Prosi.*emr WdLvfeuNe9lMMbyIWTQ: �1 � 1 S"lbm -.I CmIeIXPersm:__W !W_-15076I_x._ S'IG RWbb F/m merNnbrMOep. pmvb: , w.l ;• W Lab�tY Pot�ear rrol, -l4ir'el �Wo. 98524 ..._..._SAMPLE INFORMATION saalWalmaMlnMwl' W,r L o7-Trrs SgeSebmBon NTme eem0e c9Mded SpedalimlW'viavmmnrenn: 698D CGrojf4PV e+ bole Al/vo WA '.. type o,Samol(e;then-alf Frr 1 �- I -.r FBautine OnlriBulmn sempkyWl ZO RepeNSampm W!'1 Clbnnalcd.Yes ❑ Nc� pmmeW$ta.z�lamdRb uxx.mute; UmaSsh:ayra[vlaD nunIDer. Chbtlee R®tlua0lalal _Free_ 3.GmuMWater Pule Sourte Semple --- ---�— sIlma6aktlbytabAftlltl Nb: ❑TnpgrFtl lM) � LAhh,arM:Ya_Na_ Cebme R"".Ttl/_Fret_ OlasesunmlµPl ' lSUAxewGWI RFr Swan Ylekr SnWMlEnumemtim) l _ l ❑ E wii ❑FAY tA.f rn u.� IL SDI IL JI S�Bapa CeleW4Wermroe0y: rBwMMIONnMy MunrTOW PrCAWeq�AbMIMIYE.wf LASUSEONLY DRINRINGW IA ATER RESULTS BUSEONLY 1 ❑E.vol,r ❑Em3eEaFe 1 FemlCdiaxm.__.__ _-RYfOBni iPC�,IYI� RepMamdb Samge Reeuirzd: ❑TFlfG ❑BFeFIebpW ❑ SmFw YWmm ❑OsulP C O . Or-Cq,atrSMIDSJ i JRIF Q 2 LVIJ � sr rw,✓�m s�. .. iY_wvb.,�ra.w_+.ru_uwusnY__ lwtnna+Mservf4