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HomeMy WebLinkAboutWAT2025-00161 - WAT Application - 7/15/2025 WAT Z�1�_.5 - OCR 1 LO I• } 41 N.6 Street :; I `�' ON C 'f�l N TY Shelton,N. 6 95584 i Shelton:360-427-9670,Ext.400 = a� Public Health & Human Services 13e1fair: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! Parc,e�Identification _ Name on Applicant:\Ina elyi it 16.L j 41_, lug ate: 1`)J . L5 Mailing Address: 2)�1AC) t`?C_ 6 IcO m 11,(�.�, .etPhone: WU1 i-' 10(k 1t- I.e..6- � U, Parcel Number: r43he.1 ti.n1 . t,(11�� CI f>'�L� 0lc} 15 4 1 - OC D ''t9. 9.5OZ Type of Water System Reason for Application Public/Community Water System (2 or more X Building permit connections) ❑ Division of land: -EDICi ZU2 -Co C1 ❑ Individual water source(one connection), #of Parcels? SPL O Well 0 Boundary line adjustment ❑ 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. See WEL2025-00018 Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System r L Name of Water System: nQ.-l() , 14: (( ..- V 1!1`) j 1tcJL I l l./9.LL Water Facility Inventory (WFI) Number: ('()l'}'_ (write"none"for two-party) O I am the manager of this water system. The water system has been approved for services.There are presently I connection(s) in use. This will be the connection. O 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.\EFI Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ® Water well report(attached to application). Depth 64 ft. IN Well capacity Test(attached to application) 5 gpm >400 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. El Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water • El 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) c1 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 ROW. ❑ .Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). c��'�QrY�SU.IiI, Reviewer's Signatures: Envlron. Health: Date 9/22/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 Start Card No, iro$322S M A B R WELL REPORT Unique Well I.D. M ACQ3S$ STATE OF N71SHINGTtk1 Rater Rlyht Permit No. _ II 321 13AM1>aII Ip1DdOM' lQ !!St{- ..._.......... . _. Il..O !En. .....PlIGNI SEES......................................................... ...................- -...s.........i/+..-sec ... Tel! .a ll 3 - e ..) lAC .._..Or._EL' Coun_y..._..._ - ._ ;,6CAT10lt O!' WELL, County 10�lC1R 33i0 i'LOOIOx� 'ROAD, fi1�.T0t ....... ..,...«•.••••«••.•••.•_•. C2} AD Cr WELL for nearest address) .............._... i2a) STREET .....................s..._..._................... LOG ..._s.........-SEES.. STET {t0) � -----STET USE DOI R TIC {1) PROPOSED .,.. color. character, site of Material .E....W...«,.o Formation. Describe by aquifers and the tce.r Number of well and structure, end show thickness of penetrated.kinddh y {aJ TYPE CI: material in each stratum pees (If more than ot+e5 .� Suture of the Mettwd: eOTAIY for each change in tornettan` ��� et laaac one entry ' ..:....o.a........... '---------- ----'--- I FROM "'0 fa wi Diawter of ,cell 4 ift NATIAL j 0 I S Q t5) DIMENSIONS: SUNS: Depth of completed well N �..�... SNOW Mi» Alm !MY 0l1AVlL I ! 10 C Drilled 4S ft. SANDY IfKhllr CS AY j l0 3i O .................DETAI ...._............... WA GIAVZL It. DETAILS: ( 10 �S i67 Casing in M • Dia, from .1 ft. to t0.5 ft. SOO. OOON� j iS Casing installed: Die. from ft to ft. •10Mr COpe97[ SLID i E MILANO CASING -ft. to _._._Eft.- OMAN CLAY 1 pin. from j 5.. ... fin. 1 412 Perforations, WO C Type et pnrtoraLor Levi I CO Sl*E of perforations in. by tt. to it. j perforations from ft. to ft. j 4.1 perforations from ft. a. 0 perforations from tt. tO �.., SETS__ _ ... ....... j Screens: Y �pfL43X C Manufacturer's Name LCMTSD Model R Tie a aid size .030 from 44.6 ft, to St ft. I , tQ Dian. 4 ft. to ft. 'm f5 s'_ot size from t� }tam -SETT-- ----------- •. . . . mo Q Size of gravel , Gravel patted SO fit. I •r _ ft. tO a j Gravel Placed troll ------------- t :b whit depth? 30 ft. I Surface seal:used _ �' = Material uacd in seal 1 rater? WO AS Did any errata contain unusableDepth of strata ft. ,y L. Type of water' .. j U. Method of sealing strata off j t� .................-._a...r.._..«...TEE S..._.........� . (71y PUMP:`Manufacturer'. Name H.i. j 'u. Typt .......J+..<._......? I 0 Land-surface elevation tt I Z (M} WATER l.R��' above wean see level . (A Se atic level si tt- below too of well Date 0liii/!7 ' lbw. per square inch Date Artari.sn p'Qanure Completed O!/1S/M7 Artesian water controlled by Nark started 0!/1S!!7 ....,..•�-•_ .�1 ...._ELL TEST_: ...-._ CONSTRUCt'OR ceeriercarioso t� water level is lowered below { WELL constructed and/or accept reaponZl}pility for con- () 1. NCI1. TESTS: Drdwdown i. amount and its compliance with all static level• struction of this well. Q yie*es a pump toga made with If yai by avdo hr.. j eaehtngton well construction standards. Materials used WY1ehd gal./thin ritF. Et. drawdowa after and the information reported above are true to wy beet knowledge and belief. 4•• j DRTIZ 0 Recovery data Nater (.ev*l I N1Uf8 � a ianl {Typt or prutt) d.e Time Water ,vial Time water :curl Ziaee (person, firm. or corpora Q� ADDRESS SI 170 Licanss MO. 90SS Date of teat / ! .firer bra. )$I@tFt�l a Baiter test gal/min. £t. arnra.o.+n Air tort • gal/nin. w/ stew set at f0 ft. for 1 bra.j �yDate j Contractor' Z Artesian flow g'p'm alas a chemical analyrie made? DO I Registration No. Ioseu Date o9/25/47 L� Tu�arature of water d .G I- Printed From Mason County DMS Printed from Mason County DMS cont.JMThMVP667► . Mountain View Pumps & nitration, Inc. 32519 Mountain Highway E.Eatonville,WA 98328 (253)847-5259 Fax(253)846-3761 Email: info413mountainviewoumos.com �S 2 HR Stabilized Pump Test With Drawdown & Recovery SUN 00 R� �11©25 DATE: 05/14/2025 + ,Fifro) SYSTEM NAME: Retallick Water System ADDRESS: 3320 SE Bloomfield Rd, Shelton WA 98584 Depth of Well: 62-1/2' Static: 45' Pump Set Depth: 57' TIME ELAPSED STATIC R MSTATIC PUMPIRATNG REMARKS PUMPING LEVEL TIME(min) LEVEL (SPm) 10:15 0 45' 0' 5 10:15 30sec 47' 2' 5' 5 10:15 45sec 49' 4 0' 5' 5 10:16 1 5 5 10:16 lmin 30sec ' 51' 6' 10:16 l min 45sec 52' 7' 5 0 'so' t0:17 2 53' 8' 5 9' 3 Reduced tlo' at intake 10:17 2min 30sec 54'10:18 3 56' 11' 4 10:19 4 56' 11' 5 At Intake 10:20 5 57' 12' 5 " 10:25 10 57' 12' 5 10:30 15 10:45 30 57' 12' 5 `� 57' 12' 5 " 11:00 45 57' 12' 5 44 .. 11:15 60 57 12' 5 a` 11:30 75 57' 12' 5 11:45 90 57' 12' 5 " 12:00 105 57' 12' 5 " 12:15 120 57' 12' 5 Stabilize @ Intake 12:30 135 57' 12' 5 t. ta 1:00 1:15 165 57' 12' 5 180 57' 12' 5 44 1:30 195 57' 12' 5 2:00 210 57' 12' 5 fil 2:15 225 57' r 12' 5 .. Printed From Mason County DMS Printed from Mason County DMS RECOVERY: 15min 32sec to Recover _ TIME #MIN DEPTH TIME #MIN DEPTH TIME #MIN DEPTH 2:15 0 57' 2:15 lOsec 56' 2:15 20sec 55' 2:16 1 54' 2:17 2 53' 2:18 3 52' 2:19 4 51' 2:20 5 50' 2:21 6 49' 2:25 10 48' 2:30 15min 32sec 45' Suggestion: Technicians suggest adding a 1550gal storage tank to the system. Estimate to follow. I 11 1 _ Signature - Printed From Mason County U S Printed from Mason County CMS I . Thurston County Environmental Health 412 Lilly Rd NE •Olympia,WA 98506 I .,• •, — niuntrii CTY Dais Solve Collected 360 867-2631 COLIFORM BACTERIA ANALYSIS Time Sample COunty Collected 1 I 21 I 7,c g64 II\AEAS /1 (*) Type of Warier System(check only one b )ox 0 Group A 0 Group NB :_3(1Cleu ) Pe He 21 rivatoushold Group A and Group B Systems-Provide from Water Fealties knoniory(WA). IN 46—_ c__(>2, _c... I _ System Name: Contect Person:4 „iv., Cf. a elc Day Phone:(cAtiiii) V2,41 "1-...41,i). C.ell Phone:(tbk) c60 404SIC E-mail.jaci..ce iel U lc pe„,i,cidel,.•.Phonivi)t )4;-- 13 c2 l7 salad roam w(Nrs el mane.Wray endWoode ofelf-,, vA,P a SA • 1/4,,er t 11 (C.\XA,el 1 / ID CV- P)1 i) caE (31uomk-icA P-0 SV.v t4vr\ \PA TbS te)\-1 SAMPLE INFORMATION Sample weeded by Marne): ri . C - ‘C tf LY-1 T %)0 lil f _ Specific locsion or oddness ohms sample colecled. Specie instructions or comments: (, skoehk.61 Q-9 Type of Semple(must check only ow box of$1 thump 14 fisted below) 1,lAjtoutine OtetributIon• Semple 2.Repeat Sere*(after mat rootlets) Chlorinated:Yes No I..._. 0 Disalbution System Ctaixine Residual:Total Free Chlorinated:Yes No___ 1.Raw Water Source Sample Chlorins Residue Tote! Fret_ 0 E.cot-GWR(AR) 0 Fecal-&Ayr dre forret werearar) Unsafeleclory routine lab starter Famed Ye._ __No - 0 Assemitent monitoring(AR) Unsalsfactoni moutine cosect doe 00ther _J 1 8 I alitSseeple Collected for Information Only knestigalive._._ . Construction/Repairs Ober _ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 linsatisfackey Total Collaxm Present and li1 =1"Ydee4ted 0 Eat/fitment 0 E.coi absent Repay:went Sample Rewired: Cl Swipe too old(>30 hours) 0 TNTC 0_ Bacterial Density RSIPAr Total Cordon_ ___/100ml. E col /100ml Fecal Cable /10Orni Enterococci /100 mL liferhod Coclaletif 92238 OSM 92220 No aro Tete Received--KT- SM 9215f) 0 Enemata q•-14t-2-9 1.41)1 Doe end TiMe merged 1-• 1-44-1-5 Cole Refated2.16.A 21,or Saw.kat*(000+wow Oa 60 VC Lib 1.150 Onty . . 1 . : .., . - .- From Mason ° iinf".y_1•Q.* ' ..-- Prioted from kle.,,,on Counr1W91 11" 4414 .55 -Pt 9 't