HomeMy WebLinkAboutWAT2025-00202 - WAT Application - 11/18/2025 WAT zo o lo� .13
MASON COUNTY
OCT0 6 "415 N.6th Street
Shelton,VVA98584
Public Health & Human Services 615 ,'f": •: -`►. tt..aoo
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
Date: `I 25
Name of Applicant: p-t L:l a cd c c'
Mailing Address: CH _ G I el Phone: ni I l J
Parcel Number:
Type of Water System Reason for Application
0 Public/Community Water System (2 or more / Building permit
connections) 0 Division of land:
Individual tater source(one connection), #of Parcels? SPL
l Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
4 ❑ Other(explain)
c 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.
0 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:AEH Forms\Drinking Water Revised 15r08/2024 Page 1 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 /(fie ft.
/ >400
6 Well capacity Test(attached to application) 15 gpm gpd.
1`he we'fl-'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).
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 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).
Reviewer's Signatures:
Environ. Health: '�'"'�Y�U•1il Date 11/18/2025
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
3,
utrnxiiNtNl Di D �, `% LUt'
WATER WELL REPORT Nouccoflnlcm Nn v_VE40083 ._.
ECOLOGY Unique Ecology Well it)TngNo. DMS023 ter �,`� ir,,itt ll<.; f •
�tyipe of Work: State of Washington VI!, s i tt f_,`i.
A Cnneinrcnan Site Well Nome(if more than one well). f Ecoioy t.• ; >"
U Decommission , -> Original installation.N'01 No, Water Right Perm iUCenfticate No.. •
_ _.
Proposed the: It Domestic LI industrial 1.3 Mmucipol Prope'y Owner Name Patricia Sakas Salazar
Damming U imitation ❑lest well . C tkher_ _ Well Street Address 501 E Capital Praide Rd
C u.atlntriion Typo Medial:
_.. _ . .. ._.-,.. ___-
Method:
?r New Nell Alt nitiun )Driwii fl tilted O Cobly Tool City Shelton C'ottnty Mason
Li Doepeninpt `..l Other 71 Dug fat Air- fl lilnd-Itu;ary Tux Pitied No. 32008-42-90101
Dimensions: Diameter ofboring 6 in,to 100 a. Was a variance approved for this welt? ❑Yes U No
Depth of ovopl reed well 100 a
__... 'ryes,what wus the variance tot?
Construction Uet.Ust 1t'ah
Caaiie. E.inct 1)4111t1I0 Fwont to 'tttickne.i. Steel PVC Welded Tlte,al
�'�ia i r 6 m 0 ,0 i_ .025_in. min PI C.. I.neatiun(,cv iil`tlrin:Distant low2) li WWM n:I— TWA
11 I r tn. _ — ____ 'K-'Vi of the_AL'A;Section 8 Township 2.0N Ran 3'A'
LI I in. in. 1 Cl 0I 1- Latinate(Cxnmplc 47.12345) 47.234297
l..i I L i t in. in. I I I 11 11 --
longitude(Example:-120.12345) -1'3.065120
Perforations: ❑Yes CO No T n of r,fwaku used
y" F l)riller's Log/Construction onstruction or Decommission Procedure
L No.of I n fixation Saxe of patamtwvu in.by in Fotmntintr Describe by color.duniner,site of material and arnwture,and the kind and
f'crfumted frusta U.to ft.bcklw nomad sur5av nattily of the nttterisl in each layer penetrated,with at Ieau OM cony Ire each clamp at
3 screens: itl Yes f l NO Cl K-tacker `-> D)ctuh a information. Lac additional theeta if tivoinsmy,
yt Manktionwer's Name Alloy Machine Works Material From To
:E. Type Wire Wrapped A'.ta!el No
i. Brown lino to medium sandy Drava),tight,dry 0 20
I)c�ne�n 5'" Slat sine.018 m Mxn 95__ft.to 1 DO ft. _
_ Brown medium to coarse send ravel bass 20
o Inmate, Slot titer_at.ft ft.to R. _. _...)!A_ . .c-......._. i - ___
wet 32
aSandtl4Uter pack:❑Yes 131 Nu Site of puck material in _
' r hlnwriMti Plavctil f um_ft.Iv ft. Gray silty Oily,still,dry 32 44
Black fine sandy gravel.wet 44 51
Surface ticsI. t"3 Vas No to what depth? 18 11. Multicolored medium to coarse sar"dy gravel, 51
h:a;cri d vied in seat Benklnile Chips gray silt birdtng,tight,dry 92
!Jaiany Slrara COINAm meet?eet? U Yet C No
o type ofwotcr? Uclnkotatrata Black medium to coarse sandy gravel,loose, 92
Method of reahng errata oft' water bearing 1 C0
0
Pump;Mantifaelmer's None .. .-_ Type: _____
o
+-- H.P._,.,_ Pinup intake depth: ti. Designed ilaw iare: ..per.
0
0 Water I.rretst lnwl.snirlee elevavon shrive'mann=level 203 ft �_ ����
0/ Stkk-up of top of well cluing 1_.5 ft above pound surface
e-- Static wino level 34 I.below top of well cnsiag (late 10/15/24
7, ,Artcaian preasure_lbs.pee minty inch Date
cArhroian outer is cw trolleit by Csrop,salve,etc.) - _--......._..___............_..____-...___---...__._.....,..--....
r_
L
L Well Tests:
0
lean a pimping ng test peribrmedl An No 0 Yes i.-.> by whom''
I- Yield .,-_.._ppm with_ _ it drawslnwn after his,
Z Y ieid_ppm with R,kawdowo after_.,.,tab. _
Yield pin with N diaadnwn alter. .ho.
tn
co Retuwi)Julia(time cetu,.hap pump is tinned off wino level mcaslced from well W,_-_._-__,
c top to water level)
17 —---i
"lime Water Level TWA; k'atvr t.c.cl time Witty:Livid
u
11J Imo pumping _
I _._._.
4— real -4
o )tailor let pain with _itdrewdown after„ tau. t
+- Air test I1._gpri with stein set at 82 ft.fur 1 hrs. h Dote 10i i 5120
tiitt Attesilu flow`ppm j
- Temperature of walac 52 "F Was a chalnicol analysis made" I t Yes a.No Stan Date 10/1 ra'2020 Completed Date 10/15/2020
a
HELL CONSTRUCTION CERTIFICATION: I constructed nndlur:icr:cpt nsptms;bihly for construction of this tKal,and its almplirmec With till wn.hongtor will
construction stundunls.Materials used and the iufwnnitiva icputted above sire hue to my brit knowledge sad belief.
of
Fes- el Driller 0 Trainee.C PE-Pr ame Roger Phythian Drilling Company Arcadia Drilling Inc.
Sigiw tre Atkhiva PO Box 1790
I.icenw:No.2053 City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 10/16/2020
ICY 050.1-20(Rev 09118) If you need this document to an alternate format,please call the Water Keseturrea Pal rnm at.16O4f7-6S72.
Persons with hearing loss can call 7!!ftrr Washington Relay Serena. Persons with a speech disability CM cull877.833434/.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Patricia Salazar Well Tag#: BMS023
Phone: Depth: 100'
Well Site Address: 501 E Capital Prairie Rd, Shelton Pump Set: 84'
Date of Test: 10/20/20 Static: 31.3'
TIME GPM LEVEL RECOVERY
1 Min 15 35.6 TIME LEVEL
2 Min 15 36.55 1 Min 38
3 Min 15 37.2 2 Min 36.9
4 Min 15 37.6 3 Min 36.2
5 Min 15 37.9 4 Min 35.9
6 Min 15 38.1 5 Min 35.7
7 Min 15 38.3 6 Min
8 Min 15 38.45 7 Min
9 Min 15 38.5 8 Min
10 Min 15 38.6 9 Min
15 Min 15 39 10 Min
20 Min 15 39.35 11 Min
25 Min 15 39.6 12 Min
30 Min 15 39.9 13 Min
35 Min 15 40.05 14 Min
40 Min 15 40.15 15 Min
45 Min 15 40.4 16 Min
50 Min 15 40.6 17 Min
55 Min 15 40.8 18 Min
1 Hr 15 41 19 Min
1 Hr 10 Min 15 41.25 20 Min
1 Hr 20 Min 15 41.5 21 Min
1 Hr 30 Min 15 41.9 22 Min
1 Hr 40 Min 15 42.1 23 Min
1 Hr 50 Min 24 Min
2 Hr 25 Min
2 Hr 10 Min 26 Min
2 Hr 20 Min 27 Min
2 Hr 30 Min 28 Min
2 Hr 40 Min 29 Min
2 Hr 50 Min 30 Min
3 Hr
3 Hr 10 Min
3 Hr 20 Min
3 Hr 30 Min
3 Hr 40 Min
3 Hr 50 Min
4 Hr
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506
a�►1 ' 360 867-2631
IliURSTt)N COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
J�'l-Lrti75 Collected jam/
Moat' Day Year 8 PM C.C.
Type of Water System(check only one box) 0 Private Household
❑Group A ❑Group B ❑Other_
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name.
'
Contact Person: 124.,
Day Phone:( Cell Phone:A )
E-mail: 3 Eve.Phone:
--
S r ults to (.Print fullname,addr s an zip code;rail address)
.rC! 5.......... �. ..T ....�.. � K
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 col/-GWR(A/P) Total__
❑Fecal-Surface.Gwt,sprngs(numeration Unsatisfactory routine lab number
Filtered:Yes No
0 Assessment Monitoring(A1P) Unsatisfactory routine collect date:
❑Other
Ls I
4.( Samote Collected for Information Only
Investigative_L_ Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB SE ONLY
0 Unsatisfactory Total Coliform Present and Satisfactory
❑E.colii present ❑E.coli absent +No oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Coliform _1100m1. E.coli____ _/t00m1.
Fecal Coliform 1100m1 Enterococci I100ml.
Method Codctia$M 9223B ❑SM 9222D Date and Time1 Received,
❑SM 9215B ❑Enterolert® ?.a(, t)-5 i ;
Date and Time Analyzed. Lu Dale Reported:g 21' LS
Sample Number(DOH number plus hue digits) Lab Use Only:
Q 8 0
DOH From ammo rrn ---