HomeMy WebLinkAboutWAT2025-00142 - WAT Application - 7/9/2025 WAT - I 1 A
Ms: MASON COUNTY 415 N.6th Street
Shelton,WA 98584
Public Health & Human Services Belfan:360-427-9670,Ext.400
clfair: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: 4J 1//,4u/' /� 1t t,1 — . Date:
Mailing Address: , S,tr-ll ‘4Jp44////4-f 7f Phone: raj 2 ZZ
Parcel Number: "ZO227q--7 4i9 ZZ
Type of Water System Reason for Application /1 _
Ca' Public/Community Water System (2 or more Building permit 7-)id 025 `cub S
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain)
❑ 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. \PI `
1v4 qtAlli
Part 2: Water Connection Information n WIC.
/��Ovf
Complete the section appropriate for the type of water connection being evaluated: 1'i''nv / C
Public Water System `'
Name of Water System: 1L-1—c4 /- 2-%L4
Water Facility Inventory(WFI) Number: (write"none" for two-party)
i /l 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 ,)N/) 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 2‘6
Signature of Water System Manager Date 7/i7zi
This form may be scanned and available for public view at www.masoncountywa.gov
J:1EH Fonns\Drinking Water Revised 05/08/2024 Page I of 2
Group B Water Systems
/Satisfactorybacteriolo ical test within last to application).
9 year(attach
Individual Water Well
Cg Water well report(attached to application). De th /S7/ ft.
P P t,I
Well capacity Test(attached to application) ', gpm l00 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.
,®, Satisfactory bacteriological test within last year(attach to application).
I
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
Cl 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).
r,` V I Reviewer's�n Signatures: In
Environ. Health: C Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
RECEIVED
OCT 2 4 2024
WATER WELL REPORT I)L AK t M F N I 0,
Notice of Intent No. WE57287 WA S Rt
ECOLOGY Unique lcnloby Well II)Tag No. BPN007 Of E OIO (W Oj
Type of WIN*: NOMState of N�Avhingion
Eil Coostroction Site Weil Name(if mote than one well):
0 pewees sior ,b Original installation Not No Water Right Permit/Certificate No.
Proposed tlsr. C Daaestic 0 Industrial Municipal Properly Owner Name BILL MCTURNAL
0 Dewalering 0 Irrigation [)Tea Well 17 Other 0 E CRESTVIEW DRIVE
Well Street Address
Canstrrction Type: Mlerfrod: city SHELTON county MASON
)New well C A►eration :_Driven ❑Jetted ❑Cabe Tool b
a Deepening 0 Other Dull it Air- C Mud-awtry Tax Parcel No. 32022-77-90011
6 its.ks 150 a.
f/ter%adom: Diameter ofbcxing Was a variance approved Six this well? ❑Yes E No
Depth of compknat well I SO a.
If yes,what was the variance fur?
Caratrrrtloa Dela&
Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thalad
RID 6 in, 41 145 .25 in. 1 1 0 E.I I ❑ Location(see instructions on page 2): CI WWM or 0 EWM
DID in. — — in. ❑ I O DID NE YrlS of the NE Ya;Section 20 Township 22N Rangy 3
O I ❑ in. in. ❑ I O DID
OID in. _ _ in. 3 1 O ❑ I O Latitude(Example.47.12343)47.21285
Longitude(Example:-120.12345) -123.03504
Perlwrtlaas: 0 Yes 3 No Type of petiolate%used wry��orDaOalpltttlwiap tntniart
Na of perforations Size of pasixatiem is by_in. Formatirm:Dante by coe,chamslrR aim of fast aial and~Arc used din RGd sad
Performed from O.to_P.below ground sorbet more of the material iamb layer gaslralal.with at lean one entry for each crow of
Screens: 9 Yes 0 No Nil K-Parka b Depth 144 a, information. Use additional sheet if aeotataiy.
Manufacturer's Name JOHNSON Material From To
Type STAINLESS Model No. BROWN CLAY LOAM 0 3
Diameter 5 a re 18 a Slot site Comm 145 n.to 160 a
Diameter_ in. Skit site_ in.from_it to II. BROWN CLAY 3 12
BROWN CLAY GRAVEL 12 30
Sand/Alter park:❑Yea E No Site of pack nnneriat^in. BROWN CLAY 30 80
Materials pied from_n.to_n. GIVeY CLAY 80 120
Sartact Scot: I9 Yes 0 No To wit depth'' 19 n. GRAY CLAY AND GRAVEL 120 140
Material used in seal 3/8 BENTONITE CRP GRAVEL SAND WB 140 150
Did any strata contain unmcable water! G Yes 9 No
Type of woks? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name Type:
I I.P._ Pump intake deptb:____P. Designed Dow rale:—pm
Water lamas: land-surface elevation above mean sea level—
0.
Stick-up of top of well casing *1 a above ground surface
Static water ksel 120 a.below hop of well casing Date 10/01/2024 '
Artesian pressure lbs.per wpure inch Dale
Artesian water is controlkd by Icap,valve,etc"
Weis Tote
Wets a pumping test performed' RII No 0 Yes b by*twin'
Yield_sun with 1.drawdowa sake his.
Yield-upon with ft.drawdoww idler-hrs-
Yield_pear with_ft.drawdowa aler het.
Recovery data(hose-zero when pump is bared off- water ksel manned Crum wen
sop to water inert
Time Water Level Time Water Level Time Water Level
Date orpungoing test
Ilailcr test_gpm with_ft.dra down alter his.
Air teat 21 pen with Mem set at 149 a,for 4 br. Date 10,0112024
Menu flow_per
Temperature ofvratet •F Was a darner aa•lysa mate 0 Yes RI No Start Dale 09127/2024 Complied Date 10/01/2024
WELL CONSTRUCTION CERTIFICATION: I cosalnweded and/or accept responsibility for construction of this well,and its compliance with all Washington well
construction standards.Materials used and the information repotted above arc true to my best knowledge and belief.
a A Drilla O Trainee C PE-Print Name ROBERT LAYMON Drilling Company ADVANCED DRILLING LLC
Signature _..a.Ar(r'tat'-`''' Address 11530 SCHOOL LAND RD SW
License No.2588 City,State,Zip ROCHESTER WA 98579
II IF TRAINEE:Spnnsaa.'s License No. Contractor's
Spottaor•a Registration No.ADVAND1-804DL Date 10/01/2024
Printed Fog. 4 - 7-1
t n2MR fhti akorrrarnemt!In an allaid5rwtat,please cull the(Puler Rewrrres Atrgruar at 360-107.6472.
,r;ff lf'ruhingta a Reim'Nervier. Yerrnra ro*h a speech tMmMllty con ran n77-rr.ii-634I.
Thurston County Environmental Health
412 Lilly Rd NE •Olympia,WA 98506
��. • 360 867-2631
T
COLIFORM BACTERIA ANALYSIS _
Date Sande Collected Time Semple County
Colecied
t o 12/ 1?1 1 er6 AtitS5
Mont Oy Year t,GG 7 3L O PM
Type of Wafer System(check only one box) 0 Private Household
❑Group A gGroup B ❑Other
Group A and Group 8 Systems-Provide from Water Facades Inventory(WFI):
System Name: -.L
/90,6 k/Li
Coated Person: Oa I,L
Day Plane:54 n )2,91) 2-2 Cel Phot o 2ttl 22Art
E-mad:MthdixfA-fr /NS*.GON' Eve.Phatl*Stik'?
Sand ipett,to:eiri ftl ilo*address sm zipMe grand Wrest)
---- -egr1- r"o- -
SAMPLE INFORMATION
Sample collected by(name):
JQ lta r rti404L
Specific location or address where sample colected: Specid Instudone or comments:
3144.27?` ett
porDAM s �i ae3 G�i4u
6d'Cero�. ?%SB N E, .pbtly Or,
Typo of sample(must dredr only one box d 81 trough 04 Wed below)
1.❑Routine Distribution Semple 2.Repeat Sample(after untat routine)
Chlorinated:Yes No ❑Disbtution System
Chlorine Residual Total_Free Chl onated:Yes _No
3.Raw Water Source Sample Chlorine Residual:Total Free_
❑E.col-GVllR(MI
❑Fecal-seam.Gro,wry(nests; Unsatisfactory routine lab number:
Ftlered:Yee_No _
❑Assessment Monitoring(A/P) Unsatisfactory routine colect date:
❑Other
lsl
4.0 Sample Collected for Information Only
Investigative Construon/Repairs rr Other
���cti
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total CoHorm Present and
❑E.coi present IDE.col absent No dsNCMd
Replacement Semple Required:
❑Sample too old(>30 taus) ❑TNTC ❑_
Bacterial Density Resets:Total Colifam. /100m1. E.coN /100rd.
Fecal Coldorm /100mi Enterocood /100 ml.
Method CodelTSM 92238 ❑SM 9222D Dee and The RtotivetO 1
❑SM 92158 ❑Enterolert® lb'21`7,4 Dolt
DeeandTlneAnalyzEt 10- -Z oes lQ Z3-
Sample Wirier(COH meter a�• dgb) Lab Use Only:W t3
o a o tj -4' -4'b
' tinted From Mason° ':,1 -. r,:` DMS3-33? �)
Printed from Mason County DM