Loading...
HomeMy WebLinkAboutWAT2025-00169 - WAT Application - 9/2/2025 WAT sgQ - CC (pC7 MASON COUNTY 15N.6'Street . ' Shelton.WA 98584 Shelton:360-427-9670,Ext.400 - .0 Public Health & Human Services 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 f� Name on Applicant: (�Vpf 1f 7if / jJ7 r Date: 9A/d Mailing Address: / '/X 7 ./ �(11�C (fief � Phone: Parcel Number: (3406-,57) -O,9O'21 Type of Water System /. Reason for Application ❑ Public/Community Water System (2 or more G3" Building permit e3L9 O A -' 01038 /connections) 0 Division of land: ❑ Individual wf er source (one connection), #of Parcels? SPL reWell 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. 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 1 of 2 ,nisi► Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). • Individual Water Well pSt Water well report(attached to application). Depth q ft. at / zoli F Well capacity Test(attached to application) 20 30 gpm WO 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). T/ZYfZ(:)?..5— 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) / Satisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequat ppgf water indefinitely in the future, or guarantee compliance with all applicable WDOE water resource re y1a - Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determinati. Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chap. 36.70A ROW. ��SO4, oC f II Unsatisfactory Determination: C z/z!' ji3 �0 Applicants water supply does not appear adequate to meet the needs of its intended use for the4 ng ?/, reason(s). O'I'!,/,p0N '5 Reviewer's Signatures: �� �NT, y Environ. Health: Date 10 /f3( Z5 F�,y This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 L a "-W_ WATER WELL REPORT CURRENT Ct Original dt I'copy-Ecology,e copy-owner,Yes o:opy-Mier Notice of Intent No.W 216935 • I... oEPAIMIENT Of ) EEGOLOGY Construction/Decomluission("x"in circle) Unique Frlsiogy Well ID Tag No.13C,P 608 • ® Construction Water Right Permit No. N ❑ Decommission ORIGINAL INSTALLATION prop Owner Name Adams a- '- 0153 , Notice of Intent Number '~ pn,crosgntISE: Domestic 0 bidasodal 0 Municipal Well Street Address 1990 E.Island Lk.Drive = El h El Dakar rigaeion Trot Well D Other--------_- O City Shelton County Mason _ TYPE OF WORK: Owen's amber of well(if more than one)1 © El New well 0 Reconditioned me/red:0 Dog . ❑ Bard Cl Dtivra Location ric1/4-1/4 SWl/4 See Twn20N, R3 - ewm 17 :r=r 0 Deepened ®Cable 0 Roomy ❑kited (a,t,r Still REQUIRED) or CODIMENSIONS:Diameter of well B. inches,drilled 80 ft. W WM E Depth of completed well la Lt. . L CONSTRUCTION DETAILS Lat/l,ong Lat Deg Lat Min/Sec 'a Casing ® waaod 2' Dian.from+1 a.to -74.6& Long Deg Long Min/Sec . = bandied.: 0_►iaei oa " Dim.Mom ft.to ft. . Tax Parcel No.(Required)320065002079 0) ❑ Threodad " Dian.Prom a to a. ,= Perforations: 0 Yes 0 No • CONSTRUCTION OR DECOMMISSION PROCEDURE a.+ Typo of perforator resod • Formation:Deaibe by color,character,site of material and structure, and the land and 1.., nature of the materml in each stratum penetrated;with at lust moo entry for each change O SIZE of pafs_in by in and an.of pods_ionic a to a of information. (USE ADDITIONAL SHEETS IF NECESSARY.) " Sermons: 0 Yes 0 No 0 K-Pac Loomien FROM TO as M®E�trnrr'sNano: Johnson MATERIAL • Gravel,sand.&day Brown 0 3 Typo stainless steel Model No. + IL R+ Ulan.6'toSlot sins 12_anon-74.5 ft.to-za a. Sand,Gravel,&clay Brown 3 27 R Diem. Slot size from ft.to LI Gravel/Filter packed:❑ Yea ®No Sim of gravel/sand01 Clay,sand,&gravel 27 48 Mabciats placed from tL to a. Light brown .1-1 Surface Seal: El Yes 0 No To what depth?1,Q ft. 4.-rr Material used in seal Bentolite Clay,silt,sand,&gravel ttDid anystrata contain namable water? 0 Yes 0 No (semi compact)grey 46 54 ". • a- Type of watr? Depth of scats i' Clay,silt.sand&gravel Method of scaling stoop atf (semi compact) Brown 54 . 72 PUMP: Manafactmrr's Name Goulds I— Type:sub H.P. 11/2 O ' Clay,gravel,&sand WATER LEVELS:Land-surface elevation above room sea level ft. (compact)9reY 72 74 Static level 17' a below top of well Dam 7J9111 CU Artesian pressure Ibs per square inch Date Sand&Gravel O Artesian water is controlled by • (mc,valve,etc.) (tight per) Grey 74 78 WELL TESTS:Drawdowa is amount water level is lowered below static level Slit,sand,gravel,&day it Was a pomp test made?0 Yes 0 No If yes,by whom? CDC 78 78 Yield: m 44 dr w in.with ft. down afbn 2_las. Welt" 8 2 Yielfi gallmin.with ft drawdown alter hrs. t� Yield: ' gilhath.with _R drawdown Orr has. - .sue N-� Recovery data(Irma admit as zero color pump tweed off)(Seater level mcasemd from C 1� . O well top ra wafer level) Tine WaterLove4 Tone Watert.etel rime Wear Laval co NAR 08201i . WA State t it/N tmellt °�°°"�' of Ecology (SWRO) Baiter test gal./min.with ft.dtawkswn after hrs. • t • QAiriest gal..with stem sat at S.for hoes. aJ ArtesEst Ow g.pm. Dee Start Date Feb:4.2011 . Completed Date Feb,9;2011 .0 Temperature of water Wes a chemical analysis made? 0 Yes ® No I..... 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 arc true to ray best knowledge and belie£ ._.. Driller Engineer Trainee Name(pros) Dan Carpenter Drilling Company Carpenter> -&Pumps.LLC Driller/Engineer/Trainee Signature Address 4210 Shincke Rd.NE Driller ottraince.LiceuscNo. 2677 City,State,Zip. Olympia J WA, 98506 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: -Q rd...J1'• y„ lN` ._ _--Registration No.. _ .._..--- Date �e6 21 crv,flan m 5fl to...Allan It.,...........r.a,-.r.....»".....:........r,..-.......L.-...... ..7»........1,.1...Ill., o........-,...-0 ......)dn.mn'r A011 I Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 �jZ„ Customer: Kara Medcaif Well Tag #: BCP606 �,6k? Site Address: 1970 E Island Lake Dr, Shelton Depth: 79' OCT Date of Test: 10/3/25 Static: 26' `9 202 Pump Set: 63' R FC 1/ TIME GPM LEVEL RECOVERY 1 Min 30 41 TIME LEVEL 2 Min 30 48.9 1 Min 54.6 3 Min 30 56 2 Min 48.3 4 Min 30 62.6 3 Min 45.3 5 Min 23 65.5 4 Min 43.7 6 Min 23 65 5 Min 42 7 Min 23 65 6 Min 41.5 8 Min 23 65 7 Min 40.2 • 9 Min 23 65 8 Min 38.9 10 Min 23 65 9 Min 38 15 Min 23 65 10 Min 37.3 20 Min 20 65 11 Min 36.2 25 Min 20 64 12 Min 34 30 Min 20 64 13 Min 33.8 • 35 Min 20 63.3 14 Min 32.3 40 Min 20 63.6 45 Min 20 63.6 Total Gallons Pumped: 950 Gallons . G 1 Thurston County Environmental Health 4 412 Lilly Rd NE 6 Olympia,WA 98506 A-, 360 867-2631 TIIUrtSI•ON COUNTY -- - - s..,131121611111 ® COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected �/�, Month Day Year —' • Type of Water System(check only one box) 0 Private Househo(1 ❑Group A 0 Group B . ‘Oths'rAl /tA,tc Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): L el IN _ System Name: `� ;? (/t Contact Person: f t Day Phone:( ) Cell Phone:(% IJ} 4/ E-mallrrOoite e ,i rve.Phone:( ) • Send results to:(Print full name,address and zlp•code or emelt address) • SAMPLE INFORMATION Sample collected by(name)7 v�1�c� 4� r Specific location or address where sample' collected Special instructions or comments: 90 E- ifs-47xj•o l Type of Sample(must check only one box of#1 throug #4 listed below) 1. ^Routine Distribution Same... ' 2.Repeat Sample(after unset.routine) I Chlorinated:Yes-_-_-No. El Distribution Distribution System { I Chlorine Residual:Total_._Free Chlorinated:Yes No 1 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coil-GWR(AlP) ❑Fecal-surface,owl,ap6nes(nam e:Ion) Unsatisfactory routine lab number. Filtered:Yes__...._No _--. ---- , ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑other _ J • 3 I I • 4.0 Sample collected for Informa on Only I Investigative __ Construotl n 1 Repairs Other_____ LAB USE ONLY D INK NG WATER RESULT$ LAB USE ONLY 0 Unsatisfactory Total Coliform Present and '' Satisfactory • 0 E.coli present 0 E.coli absent Coliform detected Replacement Sample Required: I 0 Sample too old(>30 hours) ❑TNTC 0-- 1 ' Bacterial Density Results:Total Coliform 1100m1. E.coli _I1o0m1. 1 ' Fecal Coliform .J100m1 Enterococol^ /100 ml.��- Method Code: M 9223E ❑SM 9222D Date and Tlmo Received: (\! SM9215B 0 Enterolert® ri. aqs 2.S' 01 4) Date and Time Analyzed:1 '2(,l Date Reported ` : I Sample Waiter(00H number(Ls rive digilsl Lab Use Only: ItoHtForm S33f,,i19 revised 11123) l I