HomeMy WebLinkAboutWAT2026-0010 - WAT Application - 2/10/2026 WAT 20A Li - 606 / 1
ea. MASON COUNTY 415 N.6th Street
Shelton,WA 98584
Shelton:360-427-9670,Ext.400
q Public Health at 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
Name of Applicant: �� D •j,_/ /_ O b "`
Mailing Address: 0 / I761-1)/illj l- hone: ,,,,,—
Mailing `02I 7
Parcel Number: i 3 d `7,5'/0 i `1')•..
Type of Water System Reason for Application
0 Public/Community Water System (2 or more O.-Building permit Li L)
-i A (. L �t'
connections) 0 Division of land:
l$- Individual water source(one connection), #of Parcels? SPL
3- Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
0 Other(explain)
❑ 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
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Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth o� ft.
{5- Well capacity Test(attached to application) &0 gpm >400 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.
It. Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
O 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)
IA 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 6.66.040-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).
r 5u Reviewer's Signatures:
Environ. Health: Date 2/10/26
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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�j C j
WATER WELL REPORT x u`u DEPARTMENT OF Notice of Intent No. kAi / ,
1 ECOLOGY ( ll
Unique Ecology Well ID Tag No.1. t 11._17s-
Type of Work: - State of Washington
4$--Construction Site Well Name(if more than one well):
i Decommission .' Original inaatlation NOI No. Water Right Permit/Certifificate1.5V1.)50No.
/
Proposed Use: g �.pon tic ❑Industrial ❑Municipal Property Owner Name f•1�7i� rte �I, /
/
❑Dewarerin 0 Irrigation ❑Test Well ❑Other Well Street Address 3 at eJ'wx T I/i P42.
Construction Type: Method:ild ryss
.New well ❑Alteration ❑Driven ❑Jetted �I.Cable Toot City pdCounty
❑Deepening 0 Other ❑Dug 0 Air- ❑Mud-Rotary Tax Parcel N . '23 0 757 /9'2_
Dimensions: Diameter of boring (p t9--- 1.1?—ft. Was a variance approved for this well? 0 Yes No
Depth of completed well • J ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From i To Thickness Steel PVC Welded Thread
t�L. I ❑ (n in. › '3 ,5 ,zS n. �L, I ❑ ❑ I ❑ Location(see instructions on page 2): ❑ or 0 sEWM
❑ I ❑ Y� in. in. EI0 CIO 5(,3 1/4-1/4 of the 6E E Y.;Section.Township Range t(4j
• I 0 in. in. 0 I 0 0 I 0
❑ I ❑ in. in. 171 I ❑ ❑ I ❑ Latitude(Example:47.12345)�.1.3 0y�I3
Longitude(Example:-120.12345) (XI... i55-3 l7 (1
Perforations: ❑Yes $,No Type of perforator used
No.of perforations- Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
- Formation:Describe by color,character,size of material and structure,and the kind and
Perforated from ft.to R.below ground surface
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: .Yes ❑No Il i:-Packer '=> Depth`4,1_8. information. Use additional sheets if necessary.
Manufacnner'_s Names 1 D Y1 t>lel. Material From To
Type S t'ci.. .1 I 5s 5+g Model No.
Diameter s in, Slot size in.from a 31 ft.to 1,2$ft. f0 P'S D' I ( L t .
Diameter in. Slot size +
_ in.from ft.to ft. (J-0`4. C I / R;Ck5 3 2,/
IA"f ,i
Sand/Met packs U Yes 4LNo Size of pack material in. �1 tl�r 4L t j>Z Z I..._
Materials placed from ft.- to (
-ft. 5 4_41 ' `�VZ (-I l'� -7
co.a s�+�
Surface Seal: Yes ❑No 7o what depth?ZQ ft. C(h� �� �v
X
Material used in seal 5e_is C .�A t - l_'-'-rk. pc..,,,-..._4 1 2 4 O
Did any strata contain unusable water? ❑Yes a No 13` ,y`Jr) Sc"t d fr r"I 4() Zo( 2 8-
Type of water? Depth of strata I- ,--r Y-.Qcv0". 1.,,d y 22.3
Method of sealing strata off 1 11 7 Cr'LA)1.1J itL - v r a) !IT 2'2.4 Z3 g
Pump: Manctrer's Name(7'O -1 15 Type:. t.t., )m/.(S.I7 k-
ftP.j t.. Pump intake depth' ft. Designed flow rate:`D gpm
Water Levels: Land-surface elevation above mean sea level T ft.
Stick-up of top of well casing j,,, ,, ft.above ground surface Li J
Static water level5�Y)b ft.below top of well casing Date—7-1D—.e.0
Artesian pressure- lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.) GpartrfiC1't of Er^l r r
Well Tests:
Was a pumping test performed? ❑No ..Yes => by whom? F")011/9 j Yield]��gpm with ff.drawdown after hrs. rEB 10 2026
Yield,L gpm with'-.-"it drawdown after hrs.
Yield,Q_gpm with ft.drawdown after hrs.
Recovery data(time=zero when pump is turned off—water level measured from well Water Resources Ptou to t t
top to water level)
Time Water_J..evel Time Water Level Time Water Level
'Z!.c1h ?,D_
1..: 2C�1 — —
—
Date of pumping test
Bailer test_gpm with ft.drawdown after 9 hrs. ..
Air test-gpm with stem set at-R for hrs. Date
Artesian flow gpm 7 /a 7 Z Temperature of water °F Was a chemical analysis made? 0 Yes 0 No Start Date I—,..v(.1_ Completed Date 1 `'G — , 1
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 n + reported above are true to my best knowledge and belief.
*Driller 0 Trainee❑PE-Print Name 1'lG, xo�l<.- Drilling Company
Signature '1��;!C���; �+ Address
License No. t elk 1 ,. t`� -7't to) p I / City,State,Zip
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. Date
ECY 050-1-20(Rev 08/19)If need this document in an alternate format.please call the Water Resources Program at 360407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
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Thurston County Environmental Health
'ter'"� 412 Lilly Rd NE m Olympia,WA 98506
lifimay?: 360 867-2631
THURSTON ii -
""""' COLIFORM BACTERIA ANALYSIS I
Date Sample Collected—
Time Sample County
1 Collected
1 I I. Ii Pm00
Month De Year f'—O PM
Type of Water System(check only one box) Al Private Household
❑Group A ❑Group B. ❑Other_ 1
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
•
Contact Person:14mq L.000t1.4e
Day Phone:( ) 4, Cell Phone:0O )`,2,Rj /V�
E-mail:CO1C,�1a(.04211..,/L Gt 1 ..Eve.Phone:( )
Send r Its to:(Pdn II name dr �s zip a or email address)
4_
____ _-_n_v_ii_sA.titc)_
SAMPLE INFORMATION
Sample collected by(name):KC((PAZ''e-le-V/
Specific location or address where same a collected: W ppaclel instructions or comments:
h b r►1'►1 l
i last✓ , t ' ;ne, .
Type of Sample(must check only one box of#1 through#4 listed below)
. 1.Gil-Routine Distribution Sample 2.Repeat Sample(after unset.routine)
Chlorinated:Yes No 0 Distribution System
Chlorine Residual:Total,Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free_
❑E.coil—OWR(NP)
❑Fecal=Surface,GM,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes__No_ __— ^_ _
❑Assessment Monitoring(A/P) e! Unsatisfactory routine collect date:
❑other / /
S
4t .Sample Collected for Inform Ion Only
Investigative Construction Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
ElE.coll present ElE.col absent No�oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC 0
Bacterial Density Results:Total Coliform /100ml. E,coli-_ _I100ml.
Fecal Coliform ___./100m1 Enterococ amt.
~
Method Code:igSM 9223B ❑SM 9222D Da a and Tim eceived:on)
SM 9215B ❑Enterolert® I.7- 45
z ps
Date and lime Analyzed:1.'� '}3• �] �o Dale Repo d: �
Semple Number(DOHnumber plus fvedigl \' Q5.- Lab Use Only: ors
DOH Form 11331.319(revised 11123)
$32 traSVI •