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HomeMy WebLinkAboutWAT2025-00089 - WAT Application - 8/4/2025 1 S M WAT 02D67 - p©o89 MASON COUNTY 415 N.6th Street Shelton,WA 98584 .0 Shelton:360-427-9670,Ext.400 t f Public Health & Human Services Belfair:360-275-4467,Ext.400 Application for Determination of Water Adequacy Instructions 1, Complete,Parte1..,No determination can bemade until Part 1 is fully completed: .. ` Complete.only;the:portion of Part:2,applying to the;type'.of:°water connection'utilized:', "{. 3::' Submit completed application;wtth any required'.attachments for,review. 4.: :An approved'.building site plan liiust:aceonipany this;apptication._ Part 1: Applicant/Parcel Identification Name of Applicant: FjYd InL(St r Date:Mailing Address: en 6 k hG/4& mid ,A,-Phone: 060-740-360?O Parcel Number. Type of Water System • Reason for Application ❑ Public/Community Water System(2 or more ..Building permit -6 Ra `0053/ connections) O Division of land: Individual water source(one connection), #of Parcels? SPL Well O Boundary line adjustment Spring/surface water O Other(explain) O Other(explain) O 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.masoncountvwa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 - • r Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well O Water well report(attached to application). Depth 176 ft. • ❑ Well capacity Test(attached to application) 18 qpm >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. ❑ Satisfactory bacteriological test within lastyear(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.distributiorisystem,guarantee an adequate,supplyyof, water'indefinitely in the.future,'or.guarantee compliarice.with all applicable WOOL water resource regulations.' Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.O40-D`e_termination of o y ;. ,Adequacy for Building Permits are satisfied. Additional.Growth Management requirements'may apply..Ch ._ apter + 36.70A RCW: " unsatisfactory Determination: . Applicant's water supply does not appear adequate.to meet the needs of its intended use for the followingt ,reason(s). - Reviewer's Signatures: 94- rrAip ii\A/i(• ....r.� bate $ 4%25 Environ. Health: This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WAT9Z WELL REPORT DEPARTMENT OF Notice of Intent No. WE59825 ECOLOGY Unique Ecology Well ID Tag No. BNMB12 Type of Work: State of Washington ❑a Coashu Iclion Site Well Name(if more than one well): ❑Decommission Original installation NOI No. Water Right Permit/Certificate No. • Proposed lite: BO Domestic 0 Industrial 0 Municipal Property Owner Name AHHBY LLC O Dewatering O Irrigation O Test Well 0 Other i Well Street Address DUSTY LN Construction Type: Method: SHELTON County MASON I New well O Alteration O Driven O Jetted O Cable Tool City O Deepening 0 Other 0 Dug RI Air- O Mud-Rotary Tax Parcel No, 319027590022 Dimensions: Diameter of boring 6 in.,to 776 R. Was a variance approved for this well? ❑Yes 0 No Depth of completed well 176 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread Old 6 in. +1 166 .250 in. 0 I ❑ PIO Location(see instructions on page 2): El WWM or O EWM Old in. in. ❑ I ❑ ❑ I ❑ NB r/4-K of the NE 'A;Section 2 Township 19N Range 3 ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ Old in. _ _ in. ❑ I ❑ ❑ 1 0 Latitude(Example:47.12345) 47.168936 Longitude(Example:-120.12345) -123.016688 Perforations: ❑Yes IN No Type of perforator used_ No.of perforations Size of perforations in by in. Driller's Log/Conatruetton or Decommission Procedure Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft to ft below ground surface nature of the material In each layer penetrated,with at least one entry for each change of Screens: M Yes O No Ca]I Packer ' Depth ft. information. Use additional sheets If necessary. Manufacturer's Name_ Material From To Type STANLESS Model No. CLAY&GRAVEL BLUE 0 50 Diameter 8 in. Slot size 10 in.from 166 ft.to 176 ft. Diameter I in. Slot size in.from-ft,to ft. CLAY BLUE 50 60 CLAY&PEAT BLUE 60 80 Sand/Filterpack:❑Yes El No Size of pack material .___in. SAND&GRAVEL WOOD BLUE 80 95 Materials placed from ft.to ft. PEAT 95 120 Surface Sestl: gl Yes ❑No To what depth?20 ft. CLAY&GRAVEL BLUE 120 135 Material used in seal BENTONITE SAND&GRAVEL WOOD BLUE 135 158 Did any strata contain unusable water? ❑Yes M No SAND&GRAVEL H2O BLUE 158 176 Type of water? Depth of strata - Method of sealing strain off .. Pump:M:inut'eclurer's Name GOULDS Type: SUB H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stickup of top of well casing 1 ft above ground surface Static water level 112 ft.below top of well casing Date 7-15-25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve.etc.) Well Te1I; Was a pumping test perforated? O No M Yes r=J by whom? _ Yield 18 I gpm with 36 ft.drawdown after 4 his. Yield I gpm with_R drawdown after hrs. Yield I 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 WeterLevel Data of pumping test Bailer teat gpm with_ft.drawdown after—hrs. Air teet I gpm with atom set at R.for hrs. Date Artesian Row gpm Temperature of water °F Was a chemical analysis made? ❑Yes a No Start Date 6-24-25 Completed Date 7-11-25 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 O PE—Print Name MADI TROTTER Drilling Company COOLWATER DRILLING,INC. Signature !' ... .--...e: Fe - Address 10921 NW HOLLY RD License No.3387 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.COOLWDI941QM Date 7-22-25 ECY 050-1-20(Rev 11/18) Ifyou need this document in an altenrateformat,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. • 26276 Twelve Trees Ln NW Stec )11,, SPECTRA Laboratories-Kitsap Poulsbo,WA ...Where aver f(nee matters (360)8370 775 5141 • COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Semple County • Collected • Q? 1/.0 2r r La AM Meth Day Year r: ' PiPM /. O V' Type of Water System tcheck only one box) ❑Group A in Group B I .Other Group A and Group B$ystems—Provide from Water FecitSes Inventory(WFI): ID!I System Name: 13 /4Shigi Contact Person: c o ot. .J A•rt.4 !11 f.tC.i-.F( Day Plane:310 g -Crab r I Cell Plane: Emet: Eve.Phone: Send testis to:plot fuf name,Adams aylarp code or moil above for*Monk copy of modal coo LWATEL4E'irr.4.re PenwN-%1.._cm��- SAMPLE INFORMATION • Sample collected by(hams): C a°L.la of-Fti • Specific locaUen where sample collected: Special Instructions or comments: VI 17 GN Type of Sample(cheat only one box) 1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(NP) No El debd aeon system abet uaset'One) Chiorinated:Yes Q Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample I I I Unsatisfactory routine collect date: S Chlorinated:Yes No in Triggered (NP) • Chlorine Residual:TotaL._Free ❑Assessment(Al9) 4,Surface or GWI Raw Source Water Sample(Enumeration) I I .?. ❑ E.roll ❑Fecal wed Ye,_Ho 3.}Sample Cofede 1 for Intotmatron Only: -I ABu3EONLY;..•:`DRINi((NG_WAT_.ERRESULTS. LASUSE.ONLY•••• O Unsatisfactory Total Coilform Present and .Satisfactory CIE co!present ❑E,cob absent 11 Bacterial Density Results:Total Colifonn. mpn/100m1.EcoN mpn/I00mi. FecalColfonn cfu/100ml. HPC cfullml. Replacement Sample Required: 0 TNTC 0 Sample too old 0 Sample Volume 0 Damaged Container 0 Lab Reference Number � II�L 11,03Y?0v( Rec pt Temp C': Method Cod Sµgyyyg '{.COUNT/SASe222D I1 i f� �}��l 7aa repMranae tle► O�ewdue penes arovperlb 1lreJd tgrA r taruaarai l ya Mn recited ale repel h tarn,rime racy h sea*kru 6tad M 9M'A0.6111 N dnoar Phrepul DOH lob— p°oieV• 010. .^ Ibwicul raga orti imeo'%WindWwpr(4ae Ie 1I V„�( 11 sass..labnirr.nurpwwlwbarcpooINase. �.,1_ �.� hlll~Fla Wins OM.weal yBrorctrelaao+r.ra- DOH Fore ea 111 V MIA+e 06111) 3 — —. -.. .. ��