Loading...
HomeMy WebLinkAboutWAT2025-00120 - WAT Application - 6/2/2025 WAT .. 2Q25-00120 MASON COUNTY to 6 N. �'Street 041, Shelton, 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 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 of Applicant: Jc,s4o- C Date: &- `zs Mailing Address: 1St E /ti'kftso . 4Nsv• RJ Phone: zS 3-22 S-6 l S (strriD�y�c✓ wA ,ttsa Parcel Number: 7i7i.‘103).4041.3 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more tit" Building permit connections) 0 Division of land: fif Individual water source(one connection), #of Parcels? SPL El' Well ❑ 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, 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 1.AEH Forms\Drinking Water Revised 05'ORt2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well 1 Water well report(attached to application). Depth 60 ft >400 t( Well capacity Test (attached to application) II 0 gpm $ 9pd. 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. LI/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 • • Part 3: Mason County Community Services Evaluation (staff use only) IX 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:Strvt 7/9/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2ef2 e- Department Original and First Copy with 1NATER WELL REPORT Notice of WE06116 Depaent of Ecology UNIQUE WELL I.D.# _.A'�Q526._ _ Q. Swum)Copy-yawner%Copy STATE OF WASHINGTON dMers copy 7 ' e, Water Right Permit No. NIA. ,- _- (1)OWNER: llama BRA IROUT . ...._._. Address 1�4/2ND AVEJ UYALLUP_..WMI3 _-- cg (2)LOCATION OF WELL: County AAASON - _SW 1f4_SE. tr4 Sec 19_ T. u N.,R j}N_. W.IM. (2a)STREET ADDRESS OF WELL(or nearest address) i51_EMASON 8EN$QL_fa___.__......_____ in TAX PARCEL NO. 22110.3290023—.. +'=.h (3)PROPOSED USE: []Domestic ©lode OMu WFI1LOG DECOMMISSIONING PROCEDURE DESCRIPT1ON Irrigation DTest Well t]OMter _. -8: • color.chafed*.um a ma�mla end suuctiro fur nd C undue nacre d t e maledet n eachn penetrated,wit at least one entry for each dame0 L u DeWater of fire mantel mote Sweat encountered. C (4)TYPE OF WORK: Dfrrnei's number of well(If more then one) MATERIAL FROM, T s a.New Weil Method- '4-4 _ O a:Deepened E.Dug 1 eored .J5-R9�SAS AND AY 9 CL 25 [Reconditioned i_1 Cable ElDnven DROWN.SAS__- 25 III ❑DeCommiss+on LX'Rotary ❑Jetted 9BEe,!_=a,AY . 14 _ O (5)DIMENSIONS: Diameter of well SIX _ inches. � �zREY C4ALf$I,NQ..��_ GREY CLAY 62 � DDrilled _160_..._._ lest. DDepthof f well . 160-_._ C GREY SAND AN VE = 6 O (6)CONSTRUCTION DETAILS: GREY GRAVEL WIB 160 S Casing Installed: - ++ ixlwetded _._.6. - Diam from +1.5 R to __ 16.0 ft. _. ._---.. L. ! n.to ft _ Liner instated , - Dram from -___--- O 0 ;=)Threaded Dam.from ft.to—_ - A. . - C Perforations: ❑Yea NNo F3 Type of perforator used BStZE of perforations In.W._,—..___.. f4 J perforations from R b ft. O perforations from ft_b— R perforations from — ft to R 6 Screens: C Yen ®+a OK-Pec Lemon Manufacturer'sName _ _ + Type . — Model No. R Diem. Slot size from IL b It L Diam. Slot size from It.to V It — _ !C 3 GraveUFitter packed: ❑Yes (ENo 0 Size of gravel/sand r •.Tl�.�' � lb Material placed from ft,to - ft. OSurface seal: [ Yes QNo Toa4tat depth? ___...111___ tL ; y' ; • i i Z Material used in NMI BENTONITE .- _— H Did any strata contain unusable water? DYea [XjNo- :t: li I:,ft i agar O Type ofofvane? ' - , .tt sahh r._4, Method of sealing strata off manutadumes Nerve ,, (7)PUMP: GQULos H.P.P CS - 01 TYPe: S_UB_._______-..-____. ____ MEN (8)WATER LEVELS: land wrtace elevation 21,25lZ04T t9 above mean sea level rt. Wok Started 2t4(2ou .19. Completed ✓ Static level 67 ft below top ct well °ste 211212007 WELL CONSTRUCTION CERTIFICATION: 111 Artesian pressure )trot per swank troll Datese- _-. I oonstruceea and/or accept responsibility for construction of this well,and its O Artesian water is controlled by - _ compliance with all Washington well construction standards. Materials used -(CaP.Vim.sic)i-+ and the information reported above are true to my best knowledge and belief Drawdown is amount crater level is lowered below stzrtic level • {9)WELL TESTS: Type or Print Name NIGMOLAB,LERNST__ License No 21_47 .�._�..... E Was a pump test made? E]Yes EX No If yes,oy whom? (Licensed DrIwstevnaw) i Yield: galimin.with ft drawdown after hrs Trainee Name with rt. Li rinse No - tt3 Yield: galJmin. drawdow alter tra. _.^ _ -.__._..�_..__.— Q. Yield gal./min.with ft.drawdown after w_ hrs. Drilling T .P DOG DRI NG CO_ Recovery data(time taken as zero wheel pump turned off)(water level measured 4 tll �`` from well top to water level) (s�h�) V License No. 21 47__. o . Ti C Time Water Level Time Water Level me Water Level IL Dnee ) I- Address Pi/BQX 2227 BELFA_IR WA._9fl526 . - - contractors — Registtatlon No. TOPDO>ICO54RA____ .. Date 31112007 .t9 Dale of test Bailer test galfmn.with t drawdcem after _ his (USE ADDITIONAL SHEETS IF NECESSARY) Airiest e - gaumin.with stern set at 140 R for 1 ire. Ecology is an Equal Opportunity and Affirmative Action employer For Artesian flew g.p.m. Date 216/200Z special accommodation needs,contact the Water Resources Program at Terus/endure or water Was a chemical analyses made? [IYee ([No (360)407-6600. The TDD number is(360)407-6006_ Thurston CountyEnoft��ea ti 412 Lilly Rd NE a Olympia,WA 98506 P "• L... 360 867-2631 T HuRacuty cowry COUFORM BACTERIA ANALYSIS • Date Sample Collected Time Sample Cohn Collected l2 1 ►6 / t-Lif 10 :00 r,„ MtSOh Mone, Day Yogi Type of Water System(check onty one box) i'iie6l of ❑Group A ❑Group 8 "OTher 54.. �r: ''K% Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): System Name: C t(t\r Res;de-lc,,. kAlz.I( Contact Person: A vi},ra c_l+k.>` Day Pion:(1.0) Lt —64 LS Cell Phone:( )4c4 Email:6,Aptv�eytJ v�iwk;ear . Eve.Phone:( ) Sa,-•- Send navies to:(Pent hal na,rre,address and zip trade or email address) *:;" SAMPLE INFORMATION Sample collected by(name)' t a S l Specific location or address where sample collected: Special instructions or comments: ,SI MCS. - l3c.nce," R) Car t.(Av:tt./ vt/A 4$> 546 Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(alter upset.routine) Chlorinated:Yes_ No_ _ 0 Distribution System Chlorine Residua!:Total Free Chlorinated:Vas__ _No _ 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coil-GWR(A(P) ❑Fecal-surreze.cm,leder irRSPOraWf Unsatisfactory routine lab number. Fluxed:Yee__- No__ _. 0 Assessment Monitoring(AIP) Unsatisfactory routine collect date: DOther --....._.__l._._�,l 4. Semple Collected for Informebon Only `/ Investigative Construction/Repairs r_ Other LAB-USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present end ( Satisfactory 0 E.coii present 0 Emil absent o lrtorm detected Replacement Sample Required: ❑Sample too old N0 hours) ❑TNTC 0 Bacterial Density Results:Total CoeformJ10omi. Ecoli _ 1100rn1. Fecal Coilonn --- J1130m1 Enterococci JI00 nil. Method Code:�SM 92238 OSM 9222D pate and Time Reoeiro4?-4 ❑SM 92158 0 Entomb& 12 ' ��4�',7�' Dye Date end Tine Analyzer 12 ` -4 ".�""yr. 15' Sample Nunba(0014 writer*sere dipla) lab Use Only: Ql 0 8 0 cl Cz+}PA