HomeMy WebLinkAboutWAT2025-00080 - WAT Application - 5/21/2025 WAT - aor0i50
415 N.6th Street
r17it:
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
%„�+ Building,Planning,Environmental Health,Community•Health Elma:360-482-5269,Ext.400
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: I V 0✓ At ICUy Date: /.!1 a02C-
Mailing Address: (ea �Vc/ 1141JL Phone: 3'v-�i, �- 0/83
�3-31�-5 �'U RY ;hPt
Parcel Number: l�'
Type of Water System Reason for Application ,,��,,,,��������yy
❑ Public/Community Water System (2 or more Building permit g a,Qar CJ( '1
connections) 0 Division of land:
Individual water source (one connection), #of Parcels? SPL
Well 0 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)
❑ I 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.
El 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.
J^.EH Funn,t Drinking Water Revised 4 4 701 S
rilliimmmimmminuml... m.... --------14'. - Individual Water Well
Water well report(attached to application). Depth I 1 ft.
Well capacity Test(attached to application) .4 6 gpm 7 ( ` Oct 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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 14_ 15_16_22
Water use or limitation recorded N/A Yes
Well Drilled Date /1 G-rC h S Zo Z 5
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
O Method of disinfection
❑ I 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
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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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
CRev�iewer's Signatures:
'
Environ. Health: ( 1 • r Date cf2 ( )7--c
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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WATER WELL REPORT DEPARTMENT Or Notice of Intent No. WE58694
ECOLOGY Unique Ecology Well.ID Tag No. BNM865
Type at Work: Stara of Washingror.
L Constructum Site Well Name(if more thin one well):
J Decommission t Original installation NOI No Water Right Permit/Certificate No.
Proposed Use: ,M Domeacic Cl trakmtrial D Municipal Property Owner Name TREVOR VELLAY
G Dewatemg 9 Irrigation 0 Teat Well 9 Otlrr_.__
Well Street Address 60 NE MOUNTAIN VIEW DR
Contraction Type: Method:
A New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City TAHUYA .-- County MASON
0. Deepening O Other L Dug A Air- E.Mud-Rotary Tax Parcel No. 223195000904 -
Dlateasions: Diameter of boring 6 in.,to 219 ft — -Di Was a variance approved for this well? Ell Yes Lai No
Depth of compkted well 219 ft.
Comtrrctlao Details: Wall If yes,what was the variance for?
—
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
C I D 6 in. +1 209 .250 in. i 1 1 ❑ T I ❑ Location(see instructions on page 2): WWM or 0 EWM
❑ i ❑ in. _ _ in. ❑ 1 ❑ Cl 1 ❑ SE 1V a of the NE 4;Section 19 Township 23N Range 2
7 1 0 in. in. ❑ I G ❑ 1 0
❑ I in in. in. DID ❑ I ❑ Latitude(Example:47.12345) 47.46390
Longitude(Example:-120.12345) -122.98822
0 Perforations: �U Yes et No Type of perforator used. --_
No.of perforations Size ofperfuratioe in.by in. r Driller's Log/Construction or Decommission Procedure
Perfora--ed 5om ft_to ft.bc'.ow ground surface Formation:Describe by color,character,size of material and structure,and the kind and
mtare of the material in each layer penetrated,with at least one entry for each change of
Screens: 30 Yea 0 No C1/1 K-Packer ' Depth ft. ' nfouttatiat. Use additiomi sheets if necessary.
Manufacturer's Name
Type STANLESS Model No. Material From To
Diameter 6 in Sim sin 12 in.from 209 It.to 219 ft. CLAY&GRAVEL BLUE 0 55
Diameter in. Slot size in,from ft.to ft CLAY&GRAVEL BROWN 55 70
S:nd!lTtter pack: Pas No Sin tutorial rial in. CLAY&GRAVEL BLUE 70 80
Materials placed iron. ftto ft. CLAY&GRAVEL BROWN 80 90
CLAY&GRAVEL BLUE 90 100
Surface Seal: A Yes 0 No To what depth? 20 9 CLAY&GRAVEL BROWN 100 190
Material used in seal BENTONITE
the any strata contain unosab:e water? C:Yea f�No PEAT BROWN ! 190 195
Type of water? Depth of strata CLAY 8 GRAVEL BROWN 195 209
Method of sealing strata off GRAVEL H2O BROWN 209 219
Pump: Marcfacturez s Name GOULDS Type: SUB I ,
H.P. 1 16 Pump intake depth:200 ft. Designed Row rate 10 gpm
Water Levels: L -stafaee devotion above ton sea keel ft. -..-_ .__ `
and w
I Stickup of top of well easing 1 ft.ahoSe mound surface
Static water level 171 R lwtow top of well casing Dare 3.425 -__ _.-
Artesian pressure Ito.per.squirt Date
Artesian water is controlled by twee.valve.etc.)
Well Teats:
Was a pumping drat perebrmed' 0 No M Yee rT" .blr.whom?
Yield 16 gpm with 4 R drawdown alter 4 Tea.
Ill Yield gpm with_ ft.drawdown after bra.
Yield gom with ft.drawdown after hrs.
Recovery data(time-ecru when pump is turned off-water levet measured froinwef
top In wnler level) ----
Time Water Level Time Water Level Time Wafer Level
5 MIF FULL
Date of pumping tet: - ---
Bailer tear gore with___-ft.d:awdown after_hrs.
Air teat gpm with stem act at fi.for lira. Date Artesian flow_gpm J
ITetrl a amre of water 'l' Was a chemical analysis nude? G Yes 0 No _ start Date 2-14-25 Completed Date 2-27-25 I
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept'responsibility for construction of this well.and its compliance with all Washington well
construction standards.Materials used and the information reported above arts truelomy best latowiedge and belief <
re)Driller❑Trainee 0 PE- t Name MADI TROTTER Drillinj Company COOLWATER DRILLING,INC.
Signature I � Address 10921 NW HOLLY RD
License No. 3367 City,State,Zip BREMERTON WA 98312
LE TRAINEE:Sponsor's License No. Contractor'sSponsor's Signature Registration No,COOLWDI941QM Date 3-14-25
ECY 050-1-20(Rehr 1 1113) If you need this document in an alternate format.please cull llrofer Resources Program at
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360-407 6872. Persons xdth hearing lass can call 711 for Washington Relay Servlcr- Persotet.witlt a'apeech disahtliv can call
877-833-6341. ill :
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Ste.0 ;, SPECTRA LaboratOties • Kitsuu
I. R8370 Whtre rr�rrturct xmlter J
l(360)779-514I COLIFORM BACTERIA mAik
ysts FORM a. .: . ..
Date Sample Collected Time o am� County .C ;
03 lay! 75 D AN , _ . . ... .
sa,r, Del ye z _L:34 am el 451. . '
` Type of Water System(deck only one bolt
0 Group A Cl Group B RI Other_
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): r ... ...... . ...
System Name: ..
i Contact Person: < ,t..l,,
g A-T4C
Day Phone:3C0 trP- yDoS Cell Rheas'.
Ertl Eva Phan:
;...
Send revues to:PPritful nave.addreas aid zip tales email a6a»/rnYetrede apt MndYt}
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SAMPLE INFORMATION
1 Sample collected by(name): c o04 t J+I' c°
Specific location wt[ene sample collected: Special instructions or comments:
w,0Ori e (..Ake 74,kys
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y Type of Sample(check only one box) 1
1-❑Routine Distribution Sample(MP) 2.0 Repast Serrate(AR)
Chlorinated:Yes ❑ No❑ tscm stribu o i system after unsat.mute) • . ..
Unsatisfactory routine lab number .
Chlorine Resktuah Total_ Free ::
3.Ground Water Rule Source Sample --- -- --- — --- --—— ... .
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...:.
S i 1 I � urrsatslaciDry raA� day: :.. . . ..
1, 0 Triggered (PIP) Chbrird Yes No
Chbr,ge Residual:Total Free '
❑Assessment(A?)
ia Surface or GWi Raw Source Water Sample{Enurreralonj ..
1
S I !
ElE.tali ❑Fecal Filtered'es__NCB '::..::
5. .san>o+a carded tor aaoemaira,010%;
❑UniatfritiCtOrY Total Cotih,mr Present and 3 Silstactar
❑Ecoltpresent ❑Ecod absent : .: :
Sectorial Density Results:Total CcIlorm meritOOmi.Eca4 mprV1OOrrd. •
Fecal Coffom!----__..____dui1OOml. HPC .dolt mt. •
Replacement Sample Required: 0 TNTC 0 Sample too old ..
0 Sample Volume 0 Damaged Container 0--- _-- i
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Receipt temp C•. Meriod....: ...
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