HomeMy WebLinkAboutWAT2025-00023 - WAT Application - WAT -0.0-7 2: <
MASON COUNTY
COMMUNITY SERVICES
Building.Planning,Environmental Heath Community Health .Q
415 N 6"'Street, Bldg 8,Shelton WA 98584,
Shelton-(360)427-9670 ext 400 0 Belfair:(360)275-4467 ext 400 + Elma:(360)482-5269 ext 400 x
FAX(360)427-7787 ,,
i
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: J f'(.„..5e- We_trckeik f ti Date: i-U -ZS
Mailing Address: P U 50 X 12 c) ft K-ii r Phone:
Parcel Number: 2 -. 2 13 -y -0ooq&
Type of Water System Reason for Application
PublicJCommunity Water System (2 or more Building permit
connections) 0 Division of land:
• ❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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. , -\n- l0- 5, c O �
V ` V �
Part 2: Water Connection Information J° w
°D
• Complete the section appropriate for the type of water connection being evaluated:
Public Water System P
Name of Water System: -12' Il IN 6 2025
Water Facility Inventory(WFI)Number: �d N--
. MASON COUNTYE�r'�►RQh�(ENTAL h'Eq ii
(write"none"for two-party) RET
r I am the manager of this ter system. The water system has been appr ved for Z 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
P.V0-* Date 2-0-2c
This form may be scanned and available for public view at www.co.ma on.waolg
'Drinking Water
4 .
WATER WELL REPORT CURRENT
-F I" -owner,)"coo -driller Notice of Intent No. ld 135681
. r, •� origami!1'alga' .rnlad, copy copy i':i,:i.l'r,
— i i o t e c ' Unique Ecology Well ID Tag No. A FP !6:,..1 _
CI Construction/Decommission(•'x"in circle)
S)Construction Water Right Permit No.
us 0 Decommission ORIGINAL INSTALLATION Notice Property Owner Name Brad Johnson _
of Intent Number
({f Q( �,/ Well Street Address Johnson Ridge
C PROPOSED LSE: Domestic 0 Industrial 0 Municipal City Belfair County Mason
'D De Water 0 Irrigation 0 Test Well 0 other
C Location jg¢114-I/4Ssi_U4 Sec Li_ Twn 77R timd.
Q TYPE OF WORK: Owner's norther of welt(if more than one) vypx w
Al New well 0 Reconditioned Method•0 Dug D Rood ❑ OmenLttt/LOnLat DegLat Mitr/:tec
fill0 Deepened )a Cable 0 Ronny 0 Jetted g(s,t,r
EDIMENSIONS: Diameter of well fl inches,dnlbd._._277 ft. Still REQUIRED) Long Deg Long M111IStC
w. Depth of-completed well _ _ 277 R. .
= CONSTRUCTION DETAILS Tax Parcel No. 22213-77-00010
Casing'- IC Welded 6 Diam from t1 It.a 272 R
9.1 Installed: 0 Liner metalled faun from _4 b R CONSTRUCTION OR DECOMMISSION PROCEDURE
yie O 7t.r lham from R b a Fomtanon Descnbe by color.character,s.ze of nrtenal and structureand the kind and
a. -Perfaratloor 0 Yes gal No nature attic mama:in each stratum penetrated,with at least one entry for each change of
0 • Type of perforator used.- information (USE ADDITIONAL SHEETS 1F NECESSARY)
= SIZE of pert% in by aruf rho of perfs_�ftof. R a_A MATERIAL FROM TO
I. Screns: l Yes ❑ No K•Pinnie Lreatan 27Q----
vManufacturer's Name Clink 1� soil Q_ 2
Type Model No.
Di am=_ _Slot sae t 272 "n a 277 "n , Brown sand & gravelCD 8
GrardtVliter packed: 0 Yes fa No 0 Six of gravel/sand
Materials placed*art fl to R Gray l l A IQ .
Surfact Seal: C Yes ❑ No To what depth? 18 R. 1 �_
C
Material used,nseal APtruti tea t_ nrrasutFarl '-' R c1ratrQl 3'1 80
` Did any map corgain.ueusable cotter^ D Yea !�No
Type of water' Depth of stmt. - Brown sand. �8'4 F� _l60 ti
Method of scaling strata off
a..
RI
• ' PUMP: Manwrfaett.ar's None Gray Clay 1b0 260
O Type: H P.
Z WATER LEVELS: land contact elevation above me n eta level ft Fine brown sand & silts 260___ . 270
f/1 Static level . 220 A.below top of well Date
Artesian pressure lbs.per square halt'Dace Sand & gravel with roar-es 270 377
10 Artesian water is controlled by
(cap,valve,etc.)
WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump test made? ❑ Yes a No If yes,by whom?
O Yield. pal Imam with R drawdown after tea
V Yield __galintia with R drawdown after hit _ -
W Yield. eat.,min with _ft drawdown after _ he.11
O . ...Recovery data tahvn al:ern when pomp turned off)(wooer level ww..rvred fine.weft i- _ _ .
or to rent r levet)
boa Time Water Level Time Water Level Time Water Level -
—
IDate of tatCI }�j�y-
a Bola test_ 20 gal/min with__ 20 _ft drawdown after .1 _hit. t"''` ��
Airiest gal./wen.with stem tat at R.for hit '
U Arta.now gip m Date �'�21'i i tll1Et ltl SVC
Temperature of water, Was a chermcal analysis made' 0 Yes 0 No Dep2TtlllcUt )t EGa1 )r
- Start Data 3/1 5/01 completed Dan 4/5/01
WELL CONSTRUCTION CERTIFICATION: I constructed andior accept responsibility for construction of this well,and its compl'ance with all
Washington well construction standards. Materials used and the information reported above are true to my best knowledge and beli,:f.
g Driller 0 Engineer 0 Trainee Nam:il M) Drilling Company Ia vi s Dri l 1 i nt3
Duller/EngineerfrtinteSignature Address 390 NE ar, Fart, ij_
Driller or mina fair,No 1 Afl4 City.State.Zip FIFO fair, WIL.Q8528
If TRAINEE,
. Contractor's
'
Drifter's Licensed No. Registration No _DAV TSDT i 1 UClA Dale April 01
Driller's Satoshi re Ecology is an Equal 0 pm miry Employer
ECY 050-I.20(Rev 3/OS) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report.
a
Thurston County Environmental Health
`,• 412 Lilly Rd NE t Olympia,WA 98506
_ 360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
3 1 2LI 1 2c)-5 a
�_: ( t'i { •U- .$V\
Month Day Year ❑PM —
Type of Water System(check only one box) 0 Private Household 11
0 Group A 0 Group B ErOtherTW%1 `.-AC T1
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# — -- --
System Name:
Contact Person: �4;i,„.'z, 61/4.),.0e,0
Day Phone:(36u) gt% .- '65 Cell Phone:(36+ )fit-i.e
E-mail: JC�I,.t,•,'C•--c4e i€i.Fiwc".1.(:•h r Eve.Phone:( )
Send results to:(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name): c,'‘,,v i, ,, , Cicl,`
Specific location or address where sample collected: Special instructions or comments:
1C. ( E 1.,v�hs:.r. h:Lt`x ��
;c:kv.,:C \„/fly iikS
Type of Sample(must check only one box of#1 through#4 listed below) .
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes_- No 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No_
3.Raw Water Source Sample Chlorine Residual:Total Free
0 E.coli-GWR(A/P)
0 Fecal-sirtxce.owi,springs(ounmrabon) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S I —
4.❑Sample Collected for Information Only
Investigative - Construction/Repairs Other__. _
f
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present El E.coli absent
No olifomi detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Cotiform. /100m1. E.coli_ /100m1.
• Fecal Coliform_ /100m1 Enterococci__. /100 ml.
Method Code:PM 9223B ❑SM 9222D Date and Time Received:
0 SM 92158 0 Enterolert® 3,2-S \r
Date and Time Analyzed: . ..Z.S- Date Reported:1'U. 1S1 -
Sarnpte Number(DOH number plus five d).9Is) Lab Use Only: . Ch'
0 8 0 ` U62— ,eiwwlS` ft,i..a
i,lZ
— — — (fltS-)re t''A
DOH Form 1331319(revised 1123) ... ...„ . ,.-..-- n .