HomeMy WebLinkAboutWAT2025-00129 - WAT Application - 6/20/2025 _ . ----,-.7,-;---- I WAT a6 toI a ct
MASON COUNTY �U D
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�,r,r M1. � Building Planning Environmental Health,Community Health J1 1N 20 2025
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415 N 6th Street, Bldg 8, Shelton WA 98584, Street
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 + Elma: (360 '
FAX(360)427-7787
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: keJ r-1 OA l-Ck It Date: (10-
1
Mailing Address: Phone: Z _ 7I5 -4/6.7 3
Parcel Number: 3 2i_ \3 1 5 Cap 310
Type of Water System Reason for 9 permit �titApplication
�- 7 1
❑ Public/Community Water System (2 or more
connections) 0 Division of land:
a Individual water source (one connection), #of Parcels? SPL
211 Well 0 Boundary line adjustment
0 Spring/surface water 0 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
2W
XWater well report(attached to application). Depth ate-t- ft.
Well capacity Test(attached to application) 1 `0 qpm . L{C>O 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. 1
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14_15_16_22_
Water use or limitation recorded N/A Yes
Well Drilled .. Date
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)
tSatisfactory 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
ii 36.70A RCW.
HI Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
C0Revviewer's Signatures: �j f p� h -
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1171
2 of 2
Environ. Health: Date ' `/ v J `�O
CSD Director:
Date
e2b9R026.607 q 9,
WATER WELL REPORT DEPARTMENT or Notice of Intent No. WE56557
ECOLOGY Unique Ecology Well ID Tag No. BQC 497
Type of Work: State of Washington
CI Construction Site Well Name(if more than one well):
❑ Decommission r=> Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: Al Domestic ❑Industrial ❑Municipal Property Owner Name Kevin Mitchell
0 Dewatenng ❑Irrigation ❑Test Well ❑Other
Well Street Address 610 Aquila Ridge Rd
Construction Type: Method:
IC New well ❑Alteration ❑Driven ❑Jetted a❑Cable Tool City Tahuva County Mason
❑Deepening 0 Other 0 Dug ❑Air- 0 Mud-Rotary Tax Parcel No. 322187500310
Dimensions: Diameter of boring 6 in.,to 220 ft. Was a variance approved for this well? 0 Yes 0 No
Depth of completed well 220 ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
p I 0 6 in. +1 215 1/4 in. ( I ❑ EIO Location(see instructions on page 2): 0 WWM or 0 EWM
❑ I ❑ in. — — tn. ❑ I ❑ ❑ I ❑ SW IA-%of the SE 1/4;Section 18 Township 22N Range 3W
❑ 1 ❑ in. _ — in. ❑ I ❑ ❑ I ❑
❑ 1 ❑ in. _ in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.39216
Longitude(Example:-120.12345) -123.10827
Perforations: 0 Yes 0 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 from ft.to ft.below ground surface
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: Illll Yes 0 No ❑a K-Packer - Depth 212 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type stainless Model No.
Diameter 5 in. Slot size 12 in.from 215 ft.to 220 ft. Reddish brown sand&gravel 0 20
Diameter in. Slot size in.from ft.to ft. Beige sand&gravel 20 53
Peat 53 65
Sand/Filler pack:LC Yes Li No Size of pack material in. Beige till 65 104
Materials placed from ft.to ft.
Light brown fine sand&silts 104 135
Surface Seal: ]Yes 0 No To what depth? 25' ft. Blue clay 135 165
Material used in seal bentonite
Did any strata contain unusable water? 0 Yes 0 No Blue silts,clay,and some gravel 165 175
Type of water? Depth of strata Brown clay some gravel 175 195
Method of sealing strata off Brown sand&gravel wet 195 218
Brown sand&gravel water bearing 218 220
Pump: Manufacturer's Name gouldS Type: Sub
H.P. 1.5 Pump intake depth:210 ft. Designed flow rate: 12 gpm
Water Levels: Land-surface elevation above mean sea level ft.
Stick-up of top of well casing ft.above ground surface
Static water level 188 ft.below top of well casing Date
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? El No ❑Yes b by whom?
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 Water Level Time Water Level
Date of pumping test
Bailer test 16 gpm with 3 ft.drawdown after 1 hrs.}
Air test gpm with stem set at ft.for hrs. Date
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes ❑No Start Date 11/22/24 Completed Date 12/29/24
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-Print Name Emily Davis Drilling Company Davis Drilling
Signature Address 340 NE Davis Farm Rd
License No. 31 City,State,Zip Belfair,WA 98528
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.DAVISDI1100A pate DEC 2024
ECY 050-1-20(Rev 08/19)Il:vou need this document in an alternate format.please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 Jor Washington Rely Service. Persons with a speech disability can call 877-833-6341.
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