HomeMy WebLinkAboutWAT2025-00109 - WAT Application - 6/30/2025 WAT ao2 - Opp,
MASON COUNTY 415 N.6th Street
Shelton,WA 98584
Shelton:360-427-9670,Ext.400
Public Health & Human Services Belfair.360-275-4467,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part thifullycontleted.
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 5
��lcs
Name of Applicant CA c I o er� Date: � �.Qv 68/�
ur � S(e/�o�Phone: -�0 9
—Mailing Address: 3Y4 E $ 9 un ��-�,
Parcel Number: z20.2 S- /4/ Oa 6)0
Type of Water System Reason for Application
0 Public/Community Water System(2 or more
Building permit BLDa0as-D06257
connections) 0 Division of land:
individual war source(one connection), #of Parcels? SPL
C9' Well 0 Boundary line adjustment
0 Spring/surface water ❑ Other(explain)
0 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.
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
JAM Forms\Drinking Water Revised 05/08I2024 Page!of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
13 Water well report(attached to application). Depth o2 8 0 ft.
1 20 qpm >400 9Pd
l Well capacity Test(attached to application)
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.
M Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ 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 libt address adequacy of the distribution system,guarantee an adequate supply of
water,Indeffnitelyin the future,or guarantee compliance with all applicable WDOE:water resource regulations.
Recommended approval Indicates requirements of Sanitary Coder Title 6,Chapter.6.68.040-Determination of
, Adequacy for building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
46.70A RCW.
t'. Unsatisfactory Determination: '
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
• -meason(s). .
Reviewer's Signatures: 6/30/25
Environ. Health:
�5'f'° Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
miiiiiiir
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WATER WELL REPORT ��mil: j DEPARTMENT OF Notice of Intent No. WE53154
ECOLOGY Unique Ecology Well ID Tag No. BPF145
Type of 1Voric State of washington
Site Well Name(if more than one well):
O Coostntction
❑Decommission b Water Right Original iasratlationNDt No. Permit/Certificate No.
Proposed Use p Domestic 0 Industrial 0 Municipal Property Owner Name Charles Rogers
0 Dewaterimg 0 Irrigation O Test Will 0 Other Well Street Address 340 E Burgundy Rd
ComtroctionTypes Method: City0 Coble Tool Shelton County Masten
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CI Deepening 0 Other
CI Kew well Alteration 0 Dug Iii Air-Jetted 0 Mud-Rerary Tax Parcel No. 22025-14-02000
Dimensions:Diameter of boring 6 _in.,to 280 A. Was a variance approved for this well? 0 Yes C]No
Depth of completed welt 280 & If yes,what was the variance for?
Comeroedom Detain: Wall
Casing Liner Diameter From To 'Thickness Steel PVC Welded Thread Q WWM or❑EWM
Oil 0 e in. o Tr, .25 in. Q I ❑ EIO Location(see instructions on page 2):
O 10 in.
_ _in ❑ I I Township 20N Range 21.84
❑ 0 in. _ _iR ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.192391
❑ I ❑ in. __ _ _ia. ❑ I ❑ DID
Longitude(Example:-120.12345) -122.869668
Perforation: 0 Ycs O No Type of perforator used Driller's Log/Construction or Decommission Procedure
No.of perforations Size of perforations to by_inFormation:Describe by color,character,sac of material and structure,and the kind and
Perforated from__R to_EL below ground swarm nature of the material in each layer penetrated,with at least ono entry for each change of
Screens: r57 K-Pecker C Depth 274 fl. information. Use additional sheets if necessary.
Me Yea 0 No Manufacturer's Name Alloy Machine Works Material From To
Type Stainless slotted Model No. Brown silty sand and gravel, ht 0
Diameter 5' Slot size.016 is from 275 ft to 280 ft. Brown tight
loose 7 7
Diameter
Brown medium sand and gravel,
Slo sizet in.from _ft.to ft. 83
Brown medium sand,trace gravel 83 181
SandlF-dter pacts:❑Yes m No Size of pack material_is Brown medium sand,wet 181 223
Materials placed from_ft.IQ_ft. Pea gravel,brown tine sand,tight,dry 223 238
Surface Seal: O Yes 0 No To what depth? 18 a Brown fine sand,slit,some gravel 236 241
Material used in seal Bentonite chips Multi-colored gravel,brown medium sand 241 251
Did any strata contain un sable water? ❑Yes E No Brown fine sand,silt 251 257
Type of water'? of strata Multi-colored gravel,brown medium sand,water 257 280
Method of seating strata off
ii Pump: Ma muter rer's Name TYPe:
H.P._ Pump intake depth:__-ft. Designed now rate: gpm
Water Levels:Land—surface elevation above mean sea level 230 ft.
Stick-up of top of well casing 1j R above ground surface
Static water level 197 ft.below top o!well casing Date 7/25/24
Artesian pressure lbs.per sgwre inch Dale
Artesian water is oantrelled by (cap.valve,etc.)
Well Tests:
Was a pumping tut performed?[_]No 0 Yes c by whom?
Yield ppm with_fl.drawdown after hrs.
Yield_gpm with R drordowo after .sus. 1
Yield gpm with_itdrawdown after_l>K
Recovery data(time=rem 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 teat gpm with_0.dmwdosvn after_hrs.
Air test 20 gym with stem set et 260 R for 1 sus. Date 725/24
Artesian flow gpm
Temperature of water 49 e F Was a chemical analysis made? 0 Yes F3 No _ Stan Date 7/24/24 Completed Date 725/24
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WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,end its compliance with all Washington well
construction standards.Materials used and the information reported above are true to my best knowledge and belief.
El Driller 0 Trainee❑PE—Print e J sh Koepp Drilling Company Arcadia WEN;Inc.
Si arc Address PO Box 1790
License No.2874 City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No. Contractor's
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Sponsor's Signature Registration No.ARCADDI098K1 Date 725/24
ECY 050-1-20(Rev 09/18) If you need this document in an alternate format.please call the IVoter Resources Program at 360.407-6872.
Persons with hearing loss can call7l/for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
Thurston County Environmental Health
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°max' 412 Lilly Rd NE a Olympia,WA 98506 -
I%i1::.A._ 360 867-2631
THURS ON COUNTY
COLWORM BACTERIA ANALYSIS
Date Sample CoCected Time Sample County
Collected 1-. ta 11�.S 0 n
ova f�t e 3 /a;�Dp,, 1
lhoaul Oaf Year 1
Type of Water System(check only one box) El Private Household i
❑Group A 0 Group B
�ther Sin e I- I
Group A and Group 8 Systems-Provide from Water Facilities Inventory(WFI): i
ID#
System Name: E
Contact Person: C h ctr/Gf C, 0 e...Y7..? i
Day Phone:( ) Cell Phone:(y O9)57D 4[1 , f
Send results to:(Print inane;address and np cede cr emal address)
('fra�tic___$ito...4-7-.s p_ 1Po6...4..r4... •------- -
vn "?..4._____________ .1 ..
loft s.«&___.-----
SAMPLE INFORMATION.
Sample collected by(name) CMalrlcs LL, 'Pe?``��
SpedGclocationar address where edr'd: Speci
al instructions or continents:
TVG' AIL: vnd), X'bsleire,,
.• Kt.1//ya'd 6, kse e// . !fir%lcx>/• Dz4/
. Type of: .pte(must check only one box of 11$irough ft4 listed below)
1.► 'outine Distribution Sample I.Repeat Sample(after unsat.routine)
• Chlorinated:Yes No t . ElDistribution System `1
Chlorine Residual:Total Free_ Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free_ I
❑E.coil-GWR(AM)
❑Fecal-&eau,.anspiv tnurcreon) . Unca6cfactnry routine lab number:
Rllered:Yea No - _— --
❑A,w sment Monitoring(AM Unsatisfactory routine collect date:
Daher ____--f !
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40 Sample Collected for Information Only /
Investigative— Construction I Repays Other �/ I
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY i
Q Unsatisfactory Total Cdiform Present and factory - i.
��detected i
El Ecoti present 0 E.coli absent R
Replacement Sample Required: t
S
Q Sample too old(>30 hours) CI TNTC • Q i
Bacterial Density Results:Total Came), 1100m1. E.cofi /100m1. t
Fecal Coliform 1100m1 Enterococd 1100 ml.
Method Code'SM 92238 ❑SM 9222D Date and Time Received: e: 1
0 SM 92158 ❑Enterotert0 (o.le-t �Z`J t
Dale and Tara Anafyzed:{Q.I e)•Z�
Date ReporteRC 11'1
Sax*N (DOH number plus the de;is) Lab Use Only. L«� F
0. 8 0 � �4 , C.ay3xY • •
1.11,el elim, 3+Z,9 6 fi r.