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HomeMy WebLinkAboutWAT2025-00092 - WAT Application - 5/1/2025 4.... r 1 0 V WAT a6;i45 - NCO nintMASON COUNTY 415N.6'"Street Shelton,WA 98584 11 Public Health & Human ServicesShelton:360-475-4467,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 Identi ation Name on Applicant 6rek (it I-0U f LA) Date: o- I -2 )25 Mailing Address: 9Gb E. 6-1-vbr),- lei.. Phone: 3(pp, .IA I-•! 7,a`-F� 4j Parcel Number: I -II" CIO 0 IA JhekiUYL� 9� )-T Type of Water System Reason for Application Public/Community Water System (2 or more 0 Building permit�1� �� C063 connections) ❑ Division of land: Individual w er source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water 0 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) ❑ 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 . ` • Group B Water Systems 0 Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth 2 E ft. (Z i zozz. i Well capacity Test(attached to application) ?O' gpm �" gpd. I fs7?o't' 157?611 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. XSatisfactory bacteriological test within last year(attach to application). tj,/Z00?5 Individual Spring/Surface Water J ❑ 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: 7( 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. 0-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirem, , jity ply. Chapter 36.70A RCW. E Unsatisfactory Determination: 11?0 Applicant's water supply does not appear adequate to meet the needs of its intg_nded use forr} following Ills b reason(s). qso ''/� >/ N cOUNry ' 2025 Reviewer's Signatures: /� t ivi4a,/ `H Environ. Health: i)-- Date 6(( lU [ F447.ti This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of2 WATER WELL REPORT it;',;IJ DEPARTMENT OF Notice of Intent No. WE50830 ECOLOGY Unique Ecology Well ID Tag No. BNV824 Type of Work: geld State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission cz Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: IN Domestic 0 Industrial 0 Municipal Property Owner Name Don Prouty 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 691 E Strong Rd Construction Type: Method: 19 New well 0 Alteration 0 Driven ❑Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug GI Air- 0 Mud-Rotary Tax Parcel No. 22128-77-00080 Dimensions: Diameter of boring 6 in.,to 218 R. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 218 ft. If yes,what was the variance for? Construction Deceits: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread N I 0 6 in. 0 213 .025 in. al 1 0 0 I 0 Location(see instructions on page 2): El WWM or❑EWM ❑ I ❑ in _ tn. ❑ I ❑ ❑ I ❑ SE 1/4-1/4 of the SE Y.;Section 28 "township 21N Range 2W Clip in. in ❑ I ❑ ❑ 1 ❑ ❑ 1 ❑ in _ _ in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.275973 N Longitude(Example:-120.12345) -122.933073 W Perforations: 0 Yes Li]No Type of perforator used No.of perforations Size of perforations in.by_in. Driller s Log/Construction or Decommission Procedure Perforated from R to fl below ground surface Formation.Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes 0 No Ill K-Packer r , Depth 212 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5 Slot size.018 in.from 213 R.to 218 ft. Brown fine to medium sandy gravel,siltbound 0 Diameter Slot size in.from f_to ft. tight,dry 21 Brown gravelly fine sand,silty,tight,dry 21 77 Sand/Filter pack:0 Yes i7 No Size of pack material in. Materials placed from A.to R. Brown medium sandy gravel,loose,moist 77 114 Black fine sandy sharp gravel,clay binder 114 Surface Seal: O Yes ❑No To what depth? 19 ft. Material used in seal Bentonite Chips gam'dry 118 Did any strata contain unusable water? 0 Yes ©No Gray day,stiff,dry 118 126 Type of water? Depth of strata Black gravelly fine silty sand,soupy 126 138 Method of sealing strata oft Gray day,stiff,dry 138 149 Blue day,stiff,dry 149 160 Pump: Manufacturer's Name TYPe: Black fine sandy gravel,gray silt binding, 160 H.P. Pump intake depth:_ft. Designed flow rare: gpm tight,dry 164 Water Levels: Land-surface elevation above mean sea level 215 ft. Gray day,stiff,dry 164 179 Stick-up of top of well casing 1 ft.above ground surface Gray day with black gravel,tight,dry 179 184 Static water level 157 ft.below top of well casing Date 12/29/22 Artesian pressure lbs.per square inch Date Multicolored coarse sandy gravel,loose,dry 184 189 Artesian water is controlled by (cap,valve,etc.) Gray silt binding black sharp gravel 189 193 Black medium to coarse sandy gravel,heaving 193 213 Well Tests: Was a pumping test performed? El No ❑Yes by whom? Black coarse sandy gravel,water 213 218 Yield gpm with_ft.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 Watcr Level Time Water Level Date of pumping test Bailer test gpm with ft.drawdown after hrs Air test 20 gpm with stem set at 200 ft for 1 hrs. Date 12/29/22 Artesian flow gpm _ Temperature of water 51 ^F Was a chemical analysis made? 0 Yes O No Start Date 12/29/22 Completed Date 12/29/22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller 0 Trainee 0 PE—Pri hythian Drilling Company Arcadia Drilling Inc. Signature —` Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Lice o. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 12/29/22 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program al 360-407-6,472. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. 1 Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Don Prouty Well Tag #: BNV824 Phone: (360) 831-7244 Depth: 218' Well Site Address: 691 E Strong Rd., Shelton Pump Set: 160.5' Date of Test: 1/5/2023 Static 201' TIME GPM LEVEL RECOVERY 1 Min 6.66 161.5 TIME LEVEL 2 Min 6.66 161.6 _1 Min 161.5 3 Min 6.66 161.7 2 Min 161.5 4 Min 6.66 161.7 5 Min 7.9 161.7 6 Min 7.9 161.9 7 Min 7.9 162.0 8 Min 7.9 162.1 [ 9 Min 7.9 162.1 10 Min 10.3 162.1 JUN I [i - R 15 Min 10.3 162.5 d 20 Min 13.5 163.0 RECr" J 25 Min 17.7 164.0 30 Min 20.0 165.0 35 Min 20.0 165.4 40 Min 20.0 165.5 • Thurston County Environmental Health 412 Lilly Rd NE t Olympia,WA 98506 360 867-2631 THURSION COUNTY """ COLIFORM BACTERIA ANALYSIS . Date Sample Collected Time Sample County Collected ,,_/ IZ7/ ZS ❑AM 9SoA Month Day Year z� Levg Type of Water System(check only one box) ❑ Private Household ❑Group A ❑Group B grOtherS,44L b )ii1 y A ty Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: 7o&) P2p vT>/ Day Phone:(3k) '3/ . 7Z Y y Cell Phone:( ) E-mail:L13 7' Q f/ p, Eve.Phone:( ) Send rItts to:(Print Ietipame,address and zip code or email address) ate t(/204/ VWP8SL 5 •&Ali SAMPLE INFORMATION JUN lectedbyO: 1 41025 Owl) t'/Wit Specific location or address where sar ple collected: Special instructions or comments: RECEIVED 3/1 c-L roA-1, 9gs-ev Type of Sample(must check only one box of#1 through#4 listed below) 1.yerRoutine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free _ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coil-GWR(A/P) ❑Fecal-Surface,Gwl,springs(numeration( Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ['Other S 4.0 Sample Collected for Information Only • Investigative ._ Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and t Satisfactory ❑E.coli present ❑E.coli absent No liform detected Replacement Sample Required: El Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform _/100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Cod M 9223E ❑SM 9222D Date and Time Received: -O 0 9215B ❑Enterolert0 Lt -Z-l- v`t5t Date and Time Analyzed: e1 L Date Reported:-. 6.Kk Sample Number(DON number plus rive digits � ✓ Lab Use Only: A L ° A— vi t'tsB(re�eea t�rz31 5