HomeMy WebLinkAboutWAT2018-00107 - WAT Application - 11/7/2018 \
- WAT 0226 L ,- a 6( a1
' . MASON COUNTY
: ti ", =r COMMUNITY SERVICES
w a `•' Building,Planning,Environmental Health,Community Health r 1-1
I.
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •• Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-52 ext NW 0 7 2018 ,1
FAX(360)427-7787 ��l
Application for Determination of Water Adequacy BY:_ —_m®__
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 on Applicant: *A-q,... .0 n Date: I I—Lo-O-O i E 1
Mailing Address 52 -} �jO f'h y'1 , Phone: 53-� 413 -L 2-4
Parcel Number: �14co �1 LA qb
aabo5_51- 600 Lo 1
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more O Building permit
connections) O Division of land:
INt7 Individual water source (one connection), #of Parcels? SPL
51" Well , O Boundary line adjustment
O Spring/surface water
❑ Other(explain) O Other(explain)
O Replacement or Remodel (please indicate name
If you have more than one residence connected of water syste below if applicable— no
to this well, check the Public/Community Water signature require
System box.Part 2: Water Connection Information ( OkY\,CQ1\ /�
Complete the section appropriate for the type of w er connection being evaluated:
Public ater 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.ca.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) 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(attach to application).
• Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14_ 15_ 16 22__
Water use or limitation recorded N/A Yes
Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ 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)
O 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.
O 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: Date
CSD Director: Date 2 oft
WATER WELL REPORT CURRENT ~' •
Notice of Intent No: `' / '-''-' _-f
i'c'o'I'o',• Original&1st copy-Ecology,2nd copy-owner,3rd copy-driller !_' ..,.t.!? -2
Unique Ecology Well ID Tag No.r i : : z__
•Construction/Decommission("x"in circle)
' ;O Construction Water Right Permit No.
V O Decommission ORIGINAL CONSTRUCTION Notice /)
I
of Intent Number tier' 1. 3=4-1 Property Owner Name' ,-'1-4"r i.:_..._.: , ,,,
PROPOSED USE: ' - ;-. ;'T<
/❑Domestic 0 Industrial 0 Municipal Well Street Address/J:�),' i !l.�r,: t ;�rt(3
❑DeWater ❑Irrigation ❑Test Well ❑Other
" vt 2_,` ;--. County: '�'^ >P�'
TYPE OF WORK: Owner's number of well(if more than one) Cl .__ �,+r JL" ",'; EWM circle
❑New Well 0 Reconditioned Method:0 DugLocation' 1/4-1/4 1/4 Sec- Twu-- R
0 Bored ❑Driven _.-off one
❑Deepened EfCable 0 Rotary ❑Jetted E MI
I atij ong: Lat Deg Lat Min/Sec
DIMENSIONS: Diameter of well inches,drilled 75 ft. (s,t,r still
Depth of completed well ? ft. REQUIRED) r,_.ong Deg t Long Min/Sec
CONSTRUCTION DETAILS, _
Tax Parcel No. _ — 5 `7 / !)O/ t.•� /
Casing Welded �Y Diam.from +' 1 ft.to Jl U ft. CONSTRUCTION OR DECOMMISSION PROCEDURE
Installed: 0 Liner installed " Diam.from ft.to ft. Formation:Describe by color,character,size of material and structure,and the
Diam.from ft.to ft. kind and nature of the material in each stratum penetrated,with at least one
0 Threaded entry for each change of information.Indicate all water encountered.
Perforations: 0 Yes t0 No (USE ADDITIONAL SHEETS IF NECESSARY.)
Type of perforator used MATERIAL FROM TO
SIZE of perfs in.by in.and no.of perfs from ft.to ft. ij UU-+') ---7-7 aK,o rJ �)
Screens: ❑Yes ❑No ❑K-Pac Location /! / r
Manufacturer's Name f /coil-, t
-11.
*' / t1/-,-..),---....-7 f-i r x`171-- J. ≤ O
Typed t G�wfs S;'�/� . � Model No. .7 y 7
Diam. 14 r'' Slot Size r O/LJ from 7t 9 ft.to 7c ft. f .,, rr_. ^ `-�.e t� ` ' `' `..
i 1/ ''''z-
Diam. Slot Size from ft.to ft. /7 1't1� J c,/717,1' I--Y a.-/2-1 C.: �`l
Gravel/Filter packed: ElYes 0 No ,0 Size of gravel/sand �r�/ L/ <-" �,--.) `'`/L,/t.:4,4,1/ 4/
x- —
Materials placed from ft.to ft. 6..--1'J.r.,'lt�...- /—r c.,,-,,-7ms ,
r /
Surface Seal: ,E,Yes ❑ o To what depth?/F ft
Materials used in seal !_l-e diI c."4,2'7L
Did any strata contain unusable water? ❑Yes 0-No
Type of water? Depth of strata
Method of sealing strata off —
PUMP: Manufacturer's Name
Type: H.P.
WATER LEVELS: Land-surface elevation above mean sea level ft. •
Static level 1.14 1 ft.below top of well Date '—/- 0(-/
1 -
Artesian pressure lbs.per square inch Date
Artesian water is controlled by
(cap,valve,etc.)
WELL TESTS: Drawdown is amount water level is lowered below static level.
Was a pump test made? ❑Yes/®No If yes,by whom?
Yield: gal./min.with ft.drawdown after hrs.
Yield: gal./min.with ft.drawdown after hrs.
Yield: gal./min.with ft.drawdown after hrs.
Recovery data(time taken as zero wizen pump turned off)(water level measured from
well top to water level) -
Time Water Level Time Water Level Time Water Level
Date of test
Bailer test /5 gal/min.with ./4- ft.drawdown after 7 hrs.
Airtest gal./min.with stem set at ft.for hrs.
Artesian flow g.p.m. Date �7 1 ,/�/ / _//_-t:/i.„/
St
Temperature of water Was a chemical analysis made? ❑Yes ®No Start Date _/ C.:-1 Completed Date
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 J reported above are true to my best knowledge and belief.41 _
0 Driller ❑Engineer -t // T. r C e Drilling Company e r!✓1'7,..'t.--•'.i • LJ._1.-e?-1, 1-,,•-; /4'-: .
g ❑Trainee Name(Print p y
{CV-. ' L'./. N tr,-_ -vl
Driller/Engineer/Trainee Signature j!.:&I """ Address_ / /
Driller or Trainee License No. Z /1 8 City,State,Zip gat / r~•^-- •.`•fit • ---2...9<,_f:I./
r. Contractor's
If trainee,licensed driller's Registration No:`" Y'"-''= '-. `— Date -r''`/-Y"!.(-
Signature and License no. q Opportunity Employer. )
• Ecology is an Equal O ortuni Em to er. ECY 050-1-20(Rev 4/01