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HomeMy WebLinkAboutWAT2025-00201 - WAT Application - 10/3/2025 WAT 2025-00201 ea MASON COUNTY 415N.6'hStreet Shelton,WA 98584 Public Health & Human Services Shelton:360-427-9670,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 Identification Name of Applicant: Robert Bishop Date: 06/05/2025 Mailing Address: 624 Dawn Drive Phone: 360-220-0778 Parcel Number: 221127690052 Type of Water System Reason for Application © Public/Community Water System(2 or more 0 Building permit connection) 0 Division of land: l Individual water source (one connection). #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ 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 N/A Name of Water System: Bishop Water System Water Facility Inventory (WFI) Number: none , rite '`none" for two-party) ❑ I am the manager of this water system. The water em has been approved for services. There are presently connection(s) in use. is will be the connection. ❑ I am the manager of this system. Thi -.nnection will be to upgrade or change the use of an existing connection on this system (i.e.: - eational to full time). Please indicate on the following line the nature of this change: This water system i -. e and willing to provide water to this (these) connection(s)without exceeding the limits of the w- - system or any limits set by state and local regulation. Print N_.•- of Water System Manager Phone : gnature of Water System Manager Please see BLD Water Adequacy fora e9-1994 This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 1)5.'i)S,'202,i Page 1 of2 Group B Water Systems ❑ Satisfactory bacteriological test within last year (attach to application). Individual Water Well El Water well report (attached to application). Depth 130 ft. >400 2Sl Well capacity Test (attached to application) 23 gpm 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. VI 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) X 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). 'Ri15 Reviewer's Signatures: Environ. Health: Date 10/3/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 Start card No. W 13096 De rtm Original end Etiology Copy with WATER WELL REPORT Department of EOOIOgY Second Copy—Owner's Copy STATE OF WASHINGTON Third Copy—Drltler's Copy Water flight Permit No. O (1) OWNER: Nemo Robert Bishop Address Dawn Dr Allyn WA 98524 co • (2) LOCATION OF WELL: County—. Mason__ SW_u NW K sea 12 r.? N.,tt 2W Km. (2a) STREET ADDDRESS OF WELL(or nearest(Wheel) Dawn Dr Allyn WA 98524 a (3) PROPOSED USE: 21 DOmealic Industrial ❑ Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION ❑ Irrigation [7 DeWater Teat Well 11 Other 0 Formation: Describe by color. character, else of materiel and etrvotura, andchow fhlOkneee of aquifers and tho kind and salute of the material In each stratum penetrsled, Cl) Owner's number of wall wilt,al least ono entry for each change of Information.(4) TYPE OF WORK: (ltmor►thenane). MATERIAL FROM To +�' ❑ Bored a C Abandoned a Now well X7 Method: Dug O Deepened Li Cbe Driven Reconditioned 0 Rotary E( ven 0 Brown conglomorate 0 4 C — - — O (6) DIMENSIONS: Diemeterotwell 6 incise, 4 70 b Drilled I30 feet. Depth ot completed well-- t-30 ft. fan - I. (6) CONSTRUCTION DETAILS: Sand & gravel with Water -- 70 74 '° Casing installed: _ -- 6' Diem.from 0 _II.lo 125 -tt. Welded K7 ' Diem.from ft.to -b Hardpan 74 90 Liner Inetelred 0 • -ft.to ft. CD Threaded a ' Nam,from 90 105 Pertorlltiona: Yee No al Blue clay with gravel — N.0 Type of perforator used 105 130 -In.by. W. Sand & gravel. with water a SIZE of perforations-C perforation'trom tt,to II. - perforations Iron It,to n — Npertorallonalrom —II.to tt• . -- f4 - Screens: Yea® No -03.1 Menulaoturef'aNarne Houston _ -� . - - O Type stainless wire wrap Model No >+ Dlam. 5ta Blot else 40 __morn 125 N,)o 130 ft. _ .. _ — — Diem 8101 die— from It,to_ it• as Gravel pecked: Veep Nol-Xi Sisootgravel_ I..I It.IV Gravel placed from II.to___ \�n IV 18 ft. — p f_,VM Surface aael: Yoe l No❑ To whet deplh7— — _ Materiel used in seal— Retonite—- —Lt€2 �n ) Did any strata contain unusable watery YeaQ No _ _ _ 1 . TYpootwater? —Depth of strata. 1' , n 1.1 Method of eeellng stroll Olt — -- C - (7) PUMP: Msnuleclurer'eName Jacuzzi I 3 sub. H.P. 1 TYpe:- - — • (t3) WATER LEVELS: Land-surface ehonsll _rl above meanies level _ 5 Static level_ 96 It.below top of well Date _ — Artesian pressure lea,per square inch Date J Aneelan water iaconlroflodbY - p•yew,.etn}) work Marled_ —,10. Completed .. 5 (9) WELL TESTS: Drewd�wjnIs amply!water level Is lowered be wsttic level Weeapu testmade?YaaL74 Noll II yea.by whom? UU WELL CONSTRUCTOR CERTIFICATION: 17 j Yield: —aal.lmin-wilt, .0• R.drawdownliar- 1 ire,_ I constructed end/or accept responelblllly for construction of Vile well, - 1O 5 2 ;; and its compliance with ail Washington well construction standards. 3 74 ,. 10_5 4 Materiels used and the Information reported above are irue to my heel _ knowledge and belie!. Y Recovery date(thee leken as zero when pump turned oil)(water level measured 1. tram well lop to water level) Tyne water Level Tim. W.I.r Lave TWA. WelerLANAI NAME Davis Drilling _ .-- 0 106,5 3 min. .98 30 min. 96 (pnnsoN,FIRM•OR CORPORATION) (TYPE Oft PRINT) 1_ min. _ 100 — 7 min. 9Z_ — 2 mi n.— 98-5. 15 min._96.5 _ Address ,__Belfair WA 98528 Date of tear — -Uaense No. 1706 (Signed) ballot teat bel.tmin.with- .It.drawdown attar lire. ('�� I ER Contractor's Airiest gal./min.wilt,stem set el It.for— lug. o __D�t191 No,, �SDI110QA -_ Date Sept.. _,1993_ N Artesian now g p.m. Dale- - - Tamperattwa of water—Was a chomlOal analysts made? Yea® No (USE ADDITIONAL SHEETS IF NECESSARY) 0 ECYO5oI20 (tote?) •1328• O''.0,44"'la Thurston County Environmental Health 412 Lilly Rd NE t Olympia, WA 98506 360 867-2631 THURSTON COUNTY 1e1 COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County f r.. IVEp 9 ' / ads Collected g in a 7pAM a S tA, I Month Day Year C�,EP 1 ? 2Q25 Type of Water System(check only one box) ❑ Private Household Niger Street ❑Group A El Group B IA Other p 4. o t J V� Group A and Group B Systems-Provide from Water Facilities Inventory(WFI); ID# System Name: Contact Person: R0 izr.e r+ i£ p Day Phone:(°j(4,O) a U 0 .7 J 8 Cell Phone:( ) E-mail: Eve.Phone:( ) Send results to (DOl ful name,add nd ss a zip code or email address) KO 113.e r • SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: • Type of Sample(must check only one box of#1 through#4 listed below) 1.%Routine 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(AIP) ❑Fecal-Surface,GWI,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑Other / 1 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 Satisfactory ❑E.coli present ❑E.coli absent o oliform detected Replacement Sample Required: El Sample too old(>30 hours) El TNTC ❑ Bacterial Density Results:Total Coliform I100m1. E.coli 1100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code:`0`SM 9223B ❑SM 9222D Date and Time Received} [Ism 9215B ❑Enterolert® 5 Date and Time Analyzed: a} Date Reported:1 t()• Sample Number(DOH number plus live digits) Lab Use Only: 0 8 0 ? C�