HomeMy WebLinkAboutWAT2025-00043 - WAT Application - 5/19/2025 WAT alas - 4
i �, MASON COUNTY h 4 COMMUNITY DEVELOPMENT
Permit Assistance Center,Building,Planning
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (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: C,lelc ?j‘3,,6 a,k_ Date: I Z 0 ZOZ 5-
Mailing Address: � - 1T L b t? ehe. LC u)A Phone: '3(o) 1 3(— 2_7 1
Parcel Number:Z2ZZ ' 1f ctwel Z cres-Z
Type of Water System Reason for Application /�
❑ Public/Community Water System (2 or more '4 Building permit B(b �S -OOR3('
connections) ❑ Division of land:
Individual water source (one connection), #of Parcels? SPL
$= 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 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 Faciity Inventory(WFI) Number:
(write"none"fortwa-party)
❑ I am the manager of this water s tem. The water system_Das been approved for services.
There are presently connection(s) in use`This will be the _connection.
❑ I am the manager of this system. This copnectionT lllbe to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time).Thlease indicate on the following line the nature
of this change: — "-
This water systemis able and willing to provide water to this (these) connection(s)without exceeding
the limits o hewater system or any limits set by state and local regulation.
,Signs re of Water System Manager Date
ir-
This form may be scanned and available for public view at www.co.mason.wa.us.
l:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
Water well report (attached to application). Depth 2,S1 ft.
Well capacity Test(attached to application) 'O gpm ' 'too qpd.
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).
?e
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 141 1151—I 1ii 122E1
Water use or limitation recorded N/A I I Yes I—I
Well Drilled . Date
Individual Spring/Surface Water
O WDOE permit(attach to application)
O Method of disinfection
O 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
• •
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).
Reviewer's Signatures: _
e& i'l 7
Environ. Health: l� Date ` ' S
CSD Director: Date -°f
WATER WELL REPORT t-,nL'. RTMENT OF Notice of Intent No. WE44212
`LOGY Unique Ecology Well ID Tag No. BMK-667
Type of Work: StP. Nashington
lJ Construction Site Well Nam-(if more than one well): __—
❑ Decommission b Original installation NOI No. WE44212 Water Right Pennit/Certificate No.
Proposed Use: l)Domestic ❑Industrial 0 Municipal Property Owner Name Greg Barich
0 Dew atcring D Irrigation 0 Test Well 0 Other -_-
Well Street Address 100 Coon Dr N
Construction Type: Method:
J New Well 0 Alteration ❑Driven ❑Jetted 0 Cable Tool City Belfalr Co sty Mason
Ll Deepening 0 Other__- _ 0 Dug O Air- 0 NW-Rotary "Dix Parcel No. 22224-75-90 7 OO k4 z_
Dimensions: Diameter of boring 6 in.,to 234.8 fl. Was a variance approved for this well? 0 Yes Cl No
Depth of completed well 234.8 ft.
Construction Details: Wall -"" If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
O i 0 6 in. 0 227.6 .260 in. O I 0 0 I r' Location(see instructions on page 2): O WWM or 0 EWMi
❑ I ❑ in. in. ❑ I 0 0 I t NW Ya-%of the SE '/s;Section 24 Township 22 Range 02W
❑ I 0 in. in. Ll I U OIL D I ❑ in. in. ❑ 1 ❑ ❑ 1 G
Latitude(Example:47.12345)
Longitude(Example:-120.12345)
1.. Perforations: 0 Yes 0 No Type of perforator teed
$• No.of perforations Size of perforations—in by, in. Driller's Log/Construction or Decommission Procedure
oi L Perforated from R.lo—fl.below ground surface Formation:Describe by color,character,size of material and sin tare,and the kind and
nature of the material in each layer penetrated,with at least one envy for each change of
a Screens: Er Yes 0 No G:K-Packer Depth 227 fl. information. Use additional sheets if necessary.
xtnnufactrucr's Name Johnson
Material Front To
vs Type Telescopic Model No.
-E Diameter 5 in. Slot size.016 in.from 229.8 it to 234.-R. Pipe stickup 0 1
♦-
Diameter in. Slot size in.from ft.to R- Brown sand gravel 1 _ 6
o Brown hard pan with clay 6 55
c Sand/Filter pack:❑Yes ❑No Size of pack material in.
o Brown hard pan with seams of sand 55 92
Materials placed from R.to fl.
oo --- -- Brown hard pan with clay seams of fine sand
E Surface Seal: O Yes 0 No To what depth? 18 fl. and water 92 180
L Material used in seat Bentonite
o, unusable any strata contain umsble alert 0Yes ❑No Brown sand gravel clay 180 205
Type of water? Depth of strata Brown sand gravel water 205 235
O Method of sealing strata oR' Brown clay and sand 235 240
CPump: Manufacturer's Name Type: _
a FiP.— Pump intake depth: ft. Designed flow rate:—ppm
4- __
o Water Levelst Land surface elevation above mean sea level ft.
Stick-up of top of well casing fl.above ground surface
X Static water level_198.5 fl.below top of well casing Date 08/27/2021ti .✓c‘P Z 1 sLC—
} Artesian pressure_ lbs.per square inch Date
4- Artesian water is controlled by (cap.valve,etc.)
O
— Sr` O E i(12t
L Well Tests: . t_f' L a L 1f f
p \Vasa pumping test performed? ❑No ❑Yes r=> by whom? __ _
3 Yield ____ppmwith ft.drawdown after hrs. VO. St-{e De"r.:eae`::rreil4
I— Yield gpm with ft.drawdosvn after—hrs. L n t^s r-t
o Yield gpm with ft.draw down after`__-.__hrs. J( C OrO� f .k r�,s.i"
Recovery data(ti nu-zero when pump is tuned on'-sealer lewdca tusraed from w ell
oh lop to water level)
o
Time Water Level Time Water Level Time Water level
Ts —
u Date of pumping test
LU
v-. Bailer test 10__gpm with 2 fl.draw•down after 1 hrs.
O Air test gpm with stem set at ft.for hrs. Date 8/27/2021
C Artesian flow gpm
CO Temperature afwater °F Was a chemical analysis made? ❑Yes 0 No Start Date 08/24/2021 Completed Date 08/27/2021
4-
toL WELL CONSTRUCTIONCERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washingtonwell
construction standards.Materials used and the information reported above are true to my best knowledge and belief
n
s E Driller 0 Tr 'te ❑P hint me Josh Stone Drilling Company Nicholson Drilling,INC
I"' Signature — Address PO BOX 123
Licen o. 3251 City,State,Zip Port Orchard,WA 98366
IF• AINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.NICHODI1370M Date 09/10/2021
ECY 050-1-20(Rev I I/13)If you need this document in an alternate foment,please call the Water Resources Programs at 360-407-6872,
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833.6341.
,
Thurston County Environmental Health
412 Lilly Rd NE to Olympia,WA 98506
360 867-2631
T1IURS ON COUNTY -
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected �4SO 11
Z I ID i z5 d %�opr
l4ar5 Day Year
Type of Water System(check only one box) 0 Private Household
❑Group A ❑Group B ViOthe _
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: �2 ri f)AX'`Lk
Day Phone:(3 46 '� iv„,,,, Cell Phone:(3 j) 7.3 i•-
E-mailll c%` hcf ,I,�MEve.Phone:( ) 2.244
Se4 Teak s to:( t full name dress and zip code or email address)
•
CI echo c-Leis rQ_io-4-rr►aitl•_ .M_
SAMPLE INFORMATION
Samp collected by(name: •
Ct-'' qr�e-li
Specific location oMild K ress where sample collected: Special instructions or comments:
to-ic-l- e►►r t ),4 `i.g5z. ttZ. auiairti fettA—'
Type of Sample(must check only one box of#1 through#4 listed below)
1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free____
❑E.coli-GWR(A/P) _
❑Fecal-Surface,GWI,sprags(numeratcn) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other / /
S
4..Sample Collected for Information Only
Investigative Construction/Repairs X Other._
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and atisfactory
0 E.coli present ElE.coli absent o Col form detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli 1100ml.
Fecal Coliform_ /100m1 Enterococci /100 ml.
Method Code:' M 9223B ❑SM 9222D Date and Time Received:r(I-P--(Y-
❑SM 9215E ❑Enterolert® -2- t• a'' 0&t
Date and lime Analyzed: .--2_ ... t . 'Z 5 Date Reported?.t2 2-5 N1/44-
Sample Number(DOH number plus fivedigits) Lab use itr&.) Qtl.-c v
0 8 0 a 03 c-..a:, � y l
DOH Form ti33t-319 reviled 11/23) /1 1
2-Cci5.h '5 SV,7-•--