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HomeMy WebLinkAboutWAT2025-00235 - WAT Application - 11/22/2025 WAT 2025-00235 . ,,.- •i- . 4t5N.fi'"Street MASON COUNTY Shelton,WA 98584 i tt. F ' COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Bel fair:360-275-4467.Ext.400 , E3uik4ng Planning,FnvrtonmantalHoalth Community i-Icahn Erna.:360-482-5259.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. `-�Y►CadiC l�Dr// e- 1 Cb Aso a..? Part 1: Applicant/ P rcel Identifi�/a'tion Lv� f� V' ,/ Name on Applicant: I�ce / �t DCW-Cate: /�/ / Mailing Address: Mar if Cer. qi' _ s , 6l-? Parcel Number: 1ZQ?fl VVDO 2 0 Geartes Ir lAP }1ht " Reasonv for Application Type of Water Systempp ❑ Public/Community Water System (2 or more Building permit connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 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 Name of Water System: Water Facility Inventory(WFI) Number: (write"none"for two-party) 0 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. Signature of Water System Manager_ Date This form may be scanned and available for public view at www.co.mason.wa.us. J:`,EI{Forms\Drinking Water RcvliCC 4/4,2.0 i ti Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ® Water well report(attached to application). Depth 99 ft. See capacity test from >400 M Well capacity Test (attached to application) wEl.2o25.00„3 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. ® Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water O WDOE permit (attach to application) O Method of disinfection O 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. i 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: 44- Environ. Health: IRANYVY\-15 Date 11/25/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT t,... 3 DEPARTMENT OF Notice of Intent No. WE54784 ECOLOGY Unique Ecology Well ID Tag No. BPF 115 Type of Work State of Washington Construction Well Name(if more than one well): 0 Decommission e> Original installation NOi No. Water Right Permit/Certificate No. Proposed Use•. l5 Domestic ❑Industrial 0 Municipal Property Owner Name Bruce Chitester ❑Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 7530 SE Lynch Rd Construction Type: Method: El New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug Iiil Air- 0 Mud-Rotary Tax Parcel No. 22032-24-90020 Dimensions: Diameter of boring 6 in.to 117 R Was a variance approved for this well? ❑Yes CI No Depth of completed well 99 ft Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread fg ( ❑ 6 in. 0 96 .25 in. C I ❑ EI I ❑ Location(see instructions on page 2): C WWM or❑EWM ❑ I 0 in. in. 0 I 0 0 I 0 SE V.-1/4 of the NW '/.;Section 32 Township 20N Range 2W ❑ 1 ❑ in. is ❑ I ❑ DID O I ❑ in. _ _ jai: I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.179746 Longitude(Example:-120.12345) -122.962932 Perforations: 0 Yes O No Type of perforator used No.of perforations_ Size of perforations is by is Driller's Log/Construction or Decommission Procedure Perforated from ft to 8 below ground surfaceFormation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ®Yes ❑No lid K-Packer b Depth 87 ft information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5" Slot size.012 in.from 89 fl.to 94 ft. Brown silty sand and gravel 0 36 Diameter 5" Slot size.000 in.from 94 R to 99 ft. Brown silty sand and gravel,wet 36 38 Sand/Filter pack❑Yes ©No Size of pack material in Brown fine to medium sand gravel, 38 Materials placed from_ft.to ft. water(high iron) 91 Surface Seal: O Yes ❑No To what depth? 19 it Gray medium sand,black pea gravel,water 91 111 MaterialGray fine sand,lenses of clay 111 117 used in seal Bentonite chips Did any strata contain unusable water? ❑Yes ]No -- Type of water? Depth of strata Method ofu sling strata off Pump: Manufacturer's Name Type: H.P. Pump intake depth: ft Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 206 ft Stick-up of top of well casing 1.5 ft above ground surface Static water level 19 ft.below top of well casing Date 1/8/24 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E]No 0 Yes m=> 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 gpm with_R drawdown after_hrs. Air test 30 gpm with stem set at 80 ft.for 1 hrs -Date 1/8/24 Artesian flow gpm Temperature of water 49 °F Was a chemical analysis made? ❑Yes O No Start Date 1/5/24 Completed Date 1/8/24 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 El Driller❑Trainee❑PE-Print N Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Addres7g— City,Ss PO Box elto790 License No.28747 . City,State,Zip Shelton,WA 98584 IF TRAINEE.Sponsor's Lice Nfo. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/8/24 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Thurston County Environmental Health • 412 Lilly Rd NE t Olympia,WA 98506 360 867-2631 THURSTON COUNTY Sr.1111: COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County �� 1 2 6" Collected' ' 1 01 l :06 Dam JVk.5Dh Month Day Year Type of Water System(check only one box) rivate Household ❑Group A 0 Group B al Other k9 6/-t y 1 Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): I j ID# __ System Name: Contact Person: Day Phone:( ) Cell Phone:( ) E-mail: Eve.Phone:( ) • ...results to:(Print full name,address and zip code or email address) • 544/1 -;M SAMPLE INFORMATION Sam le collected by ): 56' - I if- 6 -2-22' Specific location or addresse 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.coli-GWR(AR) 0 Fecal-Somata,Gwi,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No _ — _ ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ['Other / / 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 'ID Satisfactory ❑E.coli present ❑E coil absent No'boliform detected Replacement Sample Required: • ❑Sample too old(>30 hours) ❑TNTC ❑ —_ Bacterial Density•Results:Total Coliform 1100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code:t M 9223B :ISM 9222D Date and Time Received:' ❑SM 9215E ❑Enterolert® ; D (.i�I Date and Time Analyzed: G�.' ,L o• Date Reported'� �� • Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 \. s DOH Foes*331-319(revised 11123),