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HomeMy WebLinkAboutWAT2025-00096 - WAT Application - 5/5/2025 WAT 2025-00096 MASON COUNTY I COMMUNITY DEVELOPMENT /. Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: 44687 ext 400 Elma: (360)482-5269 ext 400 FAX(360)42 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: Jeff Hughes Date: 5/5/2025 Mailing Address: PO Box 36 Grapeview WA 9854aPhone: 360-649-3152 Parcel Number: 12105-31-04020 Type of Water System Reason for Application 0 Public/Community Water System (2 or more 0 Building permit connections) 0 Division of land: p Individual water source(one connection), #of Parcels? SPL CI Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ Other(explain) 0 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) 0 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. 0 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 5/5/2025 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1,2 '2018 Individual Water Well 0 Water well report(attached to application). Depth 93 ft. O Well capacity Test (attached to application) 20 gpm >400 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. O Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14LJ 151 J 16(-1 22= Water use or limitation recorded N/A 0 Yes n Well Drilled Date Individual Spring/Surface Water 0 WDOE permit (attach to application) ❑ 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) x 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. I 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: Q AONY\1°S 6/6/25 Environ. Health: Date CSD Director: Date 2 of WATER WELL REPORT DEPARTMENT OF ECOLOGY Notice of Intent No. WE58937 Type of Work: State of Washington Unique Ecology Well ID Tag No. BQC 471 Site Well Name(if more than one well): ❑� Construction ❑ Decommission ==> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: El Domestic ❑Industrial ❑Municipal Property Owner Name Jeff Hughes 0 Dewatering 0 Irrigation ❑Test Well ❑Other Well Street Address Grapeview Loop Rd Construction Type: Method: City Grapeview County Mason E New well 0 Alteration 0 Driven 0 Jetted 1/1 Cable Tool 0 Deepening 0 Other 0 Dug 0 Air- 0 Mud-Rotary Tax Parcel No. 121053104020 Dimensions: Diameter of boring 6 in.,to 96 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 91 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 0 WWM or 0 EWM ID I CI in. +1 81 1/4 in. O 1 0 0 1 ❑ Location(see instructions on page 2): ❑ 1 0 in. in. ❑ I ❑ 0 I 0 NE 1/4-1/4 of the SW '/;Section 5 Township 21 N Range 1 W ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.335100,-122.836948 ❑ 1 0 in. _ in. ❑ 1 ❑ ❑ 1 ❑ Longitude(Example:-120.12345) Perforations: 0 Yes E No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations_in.by_in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from_ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: R Yes 0 No ❑a K-Packer 1=> Depth 78 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type stainless Model No. Brown 0 20 Diameter 5 in. Slot size 10 in.from 81 ft.to 91 clay ft. Beige sand&gravel wet 2 35 Diameter in. Slot size_ in.from fl.to ft. 35 45 Greenish brown sand&gravel wb Sand/Filter pack:0 Yes R No Size of pack material in. Greenish tight gravel 45 58 Materials placed from ft.to_ft. Beige tight gravel 58 75 Surface Seal: R Yes 0 No To what depth? 18 ft. Greenish Brown sand&gravel wb 75 81 Material used in seal bentonite Brown sand and gravel wb 81 96 Did any strata contain unusable water? 0 Yes 0 No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name goulds Type: sub H.P. 1/2 Pump intake depth:40 ft. Designed flow rate: 15 gpm Water Levels: Land-surface elevation above mean sea level_ft. Stick-up of top of well casing ft.above ground surface Static water level 4 ft.below top of well casing Date Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? 0 No 0 Yes : by whom? Yield gpm with_ft.drawdown after_hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time=zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test 28 gpm with 15 ft.drawdown after 1 hrs.} Air test _gpm with stem set at_ft.for_hrs. Date Artesian flow_gpm Temperature of water_°F Was a chemical analysis made? O Yes 0 No Start Date 4-25-25 Completed Date 5-1-25 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 are true to my best knowledge and belief. O Driller e❑PE—Print Name Emily Davis Drilling Company Davis Drilling Signal Address 340 NE Davis Farm Rd License No. 3142 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVI110OA Date March 2025 ECY 050-1-20(Rev 08/19)If you need this document in an alternate format.please call the Water Resources Program 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. i d�41 � • —WATE R MANAGEMENT MIL LABORATORIES faeac. 1516 60th St E,Tacoma,WA 1,8404 1111111111 ,COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected 1 Time Sample County Collected Month ;)ay veer ©0 y Y ek •7�" \ Type of Water System(check only one box) ❑Group A ❑Group B A a i :.._...r( va t Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# - System Name: Contact Person: Day Phone:( ) Ce�lt Phone'( e I) Email- t act 4v1.O/"{A'‘ ) Send r:- 'nn;tut name.address--Cand zip coc1_ (,r `V 4"e-A I -- 217 V 4,S V\ �J ► g Cat+w u Wit,�-- SAMPLE INFORMATION Sample colected by(name): V v `t Specific location where sample col ed Sped instructions or comments: \JAV Q\\ Typo of Sample Ogled only ore type of sample from types 1 through S below) 1.❑Routine Distribution Sample(AlP) 12 ❑ Repeat Sample(A/P) (from 6stntution system after unsat routine) Chlorinated Yes No_......__.... Unsatisfactory routine lab number: Chlorine Residual;Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: l Chlorinated;Yes No ❑Triggered(A/P) Chbrine Residual Total -__Free 0 Assessment (AlP)4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E colt ❑Fecal Filtered Yes,_,-__ No 5. .Sample Collected far Information Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and �5atisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Cohtomt _110Ornl. E.cok 110Om1. FecalColiform..___— Itt?Omt. HPC �.it ml. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑___..____._.......__._..__--_-- me r\ I Lab Reference Number J t- 1 e\V Ii Method Code: O M1/4-14W0 Receipt Terrp C`: _ 22 I Date F�poAedi tabihe Onl�„� 4� —d5— LAP lt• DOH Lab•Sample# ^I� 089 00.1F."RS:t.219:eactro0Y4n ya"ead tea pbboata,wrm dlkneiwV'?*o e00529o?awry aP 111i