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HomeMy WebLinkAboutWAT2025-00095 - WAT Application - 5/7/2025 . WAT aoa5 - 00095" MASON COUNTY 415 N.6th Street Shelton.WA 98584 ► Public Health & Human Services Shelton:360-427-9670;Ext.400 Belfair:360-275-4467,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: DrumsLAJa,((ea Date: J ,/PADR5 Mailing Address: 4/2/ E RiVLN I Phone: a53-AP.3-94.W Parcel Number: Pt2f1(/-15-g001-- Type of Water System Reason for Application 0 Public/Community Water System (2 or more Building permit BLD,2oas_00554- connections) 0 Division of land: XIndividual water source (one connection), #of Parcels? SPL gWell 0 Boundary line adjustment 0 Spring/surface water ❑ 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) ❑ 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. ❑ 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. 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.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of 2 A Y Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth ft. ,Well capacity Test (attached to application) ___gpm > Ugpd. 1The 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 within last year (attach to application). 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 • • 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: Environ. Health: D '/71 Date C ( O 2 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE57520 ECOLOGY Unique Ecology Well ID Tag No. BQC033 Type of Work: W State of Washington O Construction Site Well Name(if more than one well): O Decommission v Original installation NOt No. Water Right Permit/Certificate No. Proposed Use: ©Domestic ❑Industrial ❑Municipal Property Owner Name Tom Waller ❑Dewatering 0 Irrigation ❑Test Well ❑Other Well Street Address 427 E Rivendell Rd Construction Type: Method: E New well ❑Alteration 0 Driven ❑Jetted ❑Cable Tool City Grapeview County Mason ❑Deepening ❑Other 0 Dug ©Air- 0 Mud-Rotary -lax Parcel No. 22116-75-90072 Dimensions: Diameter of boring 6 in.,to 92 ft. Was a variance approved for this well? 0 Yes ❑a No Depth of completed well 89 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread • 0 6 in o 82 .25 in. O I ❑ IM I ❑ Location(sec instructions on page 2): WWM or 0 E WM ❑ I 0 in in. ❑ I ❑ DID NE '/-1/4 of the SE '/;Section 16 Township 21N Range 2W ❑ I ❑ in. _ _ in. ❑ I 0 ❑ I 0 ❑ I 0 in. in. ❑ I ❑ O I ❑ Latitude(Example:47.12345) 47.30724 N Longitude(Example:-120.12345) -122.93580 W _ Perforations: ❑Ycs RI No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Formation:Describe by color,character,size of material and structure,and the kind and Perforated front ft.to R.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑a Yes ❑No O K-Packer r Depth 81 ft information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire-wrapped Model No. Diameter 6" Slot size.016 in.from 82 ft.to 87 ft. Gray fine to medium silty gravel 0 8 Diameter 5" Slot size.000 in.from 87 ft.to 89 ft. Grayish brown fine sand and gravel,loose 8 12 Gray multi-colored silty fine to medium gravel, 12 Sand/Filter pack:❑Yes a❑No Size of pack material in loose,dry 23 Materials placed from_ft.to ft. Brown fine gravelly silty sand,loose,dry 23 42 Surface Seal: 9 Yes ❑No To what depth? 18 ft. Brown fine gravelly silty sand,loose,moist 42 67 Material used in seal Bentonite chips Did any strata contain unusable water? ❑Yes ©No Reddish brown fine to coarse silty,gravelly sand, 67 Type of water? Depth of strata water bearing 90 Method of sealing strata off Gray fine to medium siltbound sand and gravel 90 moist 92 Pump: Manufacturer's Name Type: FI.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 175 ft. Stick-up of top of well casing 1_5 ft.above ground surface Static water level 45 ft.below top of well casing Date 12/11/24 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc) Well Tests: Was a pumping test performed? a❑No ❑Yes by whom? Yield gpm with_f 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 gpm with_ft.drawdown after_hrs.Air lest 15 gpm with stein set at 70 ft.for 1 hrs. Date 12/11/24 Artesian flow ppm -� Temperature of water 51 °F Was a chemical analysis made? U Yes El No Start Date 12/10/24 Completed Date 12/11/24 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well constriction standards.Materials used and the information reported above are true to my best knowledge and belief. 0 Driller ID Trainee❑PE—Print Na e Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 12/11/24 ECY 050-1-20(Rev 09/18) If you need this document in an alternate formal,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 call877-833.6341. vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 ysxagNeB 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 12/27/2024 1 2 3 0 ❑a� MASON Mcrth Day Yew PM Type of Water System(check only one box) ❑Group A ❑Group B I]Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID## System Name TOM WALLER Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( Email: Eve.Phone:( Send results to:(Print full name,address and zip code or e-mail; anetacgarcadiadrilling corn AND jennaarcadiadrilling corn SAMPLE INFORMATION Sample collected by(name):SHAD Specific location where sample collected: Special instructions or comments: 427 E Rivendell Rd, Grapeview Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP) Chlorinated:Yes No (from distribution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample Unsatsfactory routine collect date: S 1 I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) S ❑E.co/i ❑Fecal Fitered Yes No 5 ❑3 Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY El Unsatisfactory Total Coliform Present and (it3 Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Colifonn /100m1. E.coli 1100m1. Fecal Colifomt /100m1. HPC /1 ml. Replacement Sample Required: 0 TNTC ['Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date,Tirre Received. Lab Reference Number I? Z-71Z -{" y 12-21 —1 Receipt Temp C Method code S M 9223 B Date Reported to DOH Lab Use Only: DOH Lab-Samptete 285- 12277 DCC Fcr'nl331.319teYecnewli7)•11 you noel tas pdcaOm n en animals,/ulna cal K05250127(TOW ry eat rn).