HomeMy WebLinkAboutWAT2026-00025 - WAT Application - 2/3/2026 WAT 0 t '&- CO
r 415 N.6t Street
Shelton,WA 98584
Shelton:360=427-9670,Ext.400
Public Health & 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/ P reel Id ntific tion
Name on Applicant: tr'ISA ate: "� I
Mailing Address: 931 l Si- L-tet S Phone: A__1(0 a-32 If 1 LI
Parcel Number: 0,97.2_4113 Not ato
Type of Water System Reason for ApplicaApplication ��
❑ Public/Community Water System (2 or more Building permit IZIOROgIffY—W I b-7
connections) ❑ Division of land:
Individual water source(one connection), it of Parcels? SPL
Well O Boundary line adjustment
O 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.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2
Group B Water Systems
Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
0-a
Water well report(attached to application). Depth ft.
pi Well capacity Test(attached to application) ZO 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.
IV 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
O
Part 3: Mason County Community Services Evaluation (staff use only)
gj 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.
0 Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
� /NoW4' L Reviewer's Signatures: 3/4/26
Environs Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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gl WATER WELL REPORT :t.'o°'' DENAIii'MENT 01= Notice of intent No. WE62487
ECOLOGY Unique Ecology Well ID Tag No. BPF070
$ TypcofWork: state of Was hington Site Well Name(if more than uricwIl):
aq- CJ Construction
U ❑ Decommission e? Original installation NOI No. Water Right.PennIt/Ccriiticatc No,
I.
- Proposed Use: I l Domestio 0 Industrial 0 Municipal Property Owner Name Wendy Atkinson
0 Dewatertng 0 irrigation ' 0 Test Well ❑Other
Well Street Address 7240 E Grapevlew Loop Rd
Construe don Type: Method:
C]New well 0 Alteration 0 Driven 0 Jetted O Cable Tool City Allyn County Mason
g 0 Deepening 0 Other LI ling tl Air- ❑Mud-Rotary Tax Parcel No. 122291390010
a Dimensions: Diameter of boring 6 in.,to 100 ft.
Was a variance approved for this well? O Yes ®No
A Depth aferimpleted welt 100 .tt,
E. Construction Detnilst Wall If yes,what was the variance for?
c, Casing Liner Diameter From To Thickness Steel PVC Welded Thread
11 I 0 -e in. 0 t66_ -026 in. !3 I ❑ El ❑ Location(sec instruclions on page2): O WWIvf or 0 EMI
Oh 0 I 0 in. in. 0 I 0 0 I 0 SW t4—,ofthe NW V;Section 29 Township 22N Range 1W ,
3g O I ❑ in. in• ❑ I ❑ DIG Latitude(Example:47:12345) 47.367597 N
ffi' ❑ I ❑ in. ...__. — —in. ❑ I ❑ DID
: Longitude(lixantpie:-120.12345) -122,829486 W
O Perforations:. 0 Yes LI No Type ofperfoiator used ,
s Log/Co ns trticlien or Decant-missionProcedure
• No.of perforations_ Size of perforations—in.by it Formation:Describe by color,chanter,sire of material and etntcture,and the kind and
C' Perfantted from I.to—ft.below ground surface nature of the material in each layer penetrated,With at least one entry for each change of
Screens: CI Yes 0 No li IC-Packer ' ' Depth 94 ft, inforruntion. Use additional sheets if necessary.
Ninth:fieturer'aName Alloy Machine Works Material From To
Typo Wire Wrapped Model No,
Diameter&_ Slot size,016 in.from 95 ft.to 100 it, Brown fine sandy Sharp gravel,Silty,tight,dry 0 3
Diameter Slot size in.Rout �-n.to 4. Black fine sandy gravel,gray slily clay binder, 3
tight,dry 12
SaodQ No size of/Filler pack:0 Yes pack material—in. Brown One sandy gravel,slit hound,dry,tight 12 20
Materials placed from ft.to 6.
Brown medium wet sand,loose 20 24
Surface Seali 11 Yes D Na To what depth? 10 it. • Brown clay,stiff,dry 24 32
Matcrialused in seal Bentonite Chips Gray dley,stiff,dry 32 51
Did any strata contain unusable water? ❑Yes El No
Iype-ofwater? Depth ofsuata Brown fine silty loose wet sand 61 53
Method of seating strata oil Grey clay,stiff,dry 65 53 _
Gray silt,wet 66 86
Plump; Manufacturer's Name Trim: Gray sticky clay,dry 66 71
H.P. Pmnp intake depth: A. Designed flow rata; gpns Green heaving silt with gray clay chunks 71 77
Water Levels:Land-swftrce elevation above mean sea level 1e n. Gray silly clay,soft,moist 77 _ 79
Stick-up of top of well casing 2 ft.above ground surface Gray sticky clay,dry 79 91
Static water lovel 0 fl.below top of well casing Date 6/7/23
Ariosinnpra-sere—lbs.per square inch Date Brown medium sandy gravel,loose,water 9i 09.6
Artesian water is controlled by (cap,valve,eta) Brown medium sandy sharp gravel,tight,wet 99.6 100
Well Tests:
Was a pumping test perforated? ClNo ❑Yes �1) by whom?
Yield gpmwith ft.dmwdownatter hrs,
Yield gpnr with_ft.dmwdown after hrs.
Yield gpm with tt:dmkdoivn after hrs, V
't
Recovery data Aline.-zero when pump is turned off—water level measured from wall °�
top to water level)
Time Water Level Time Water Level Time Water Level 0 C 1 1 / 2079
- WA State Department
Date of pumping test of Ecology (SWRO)
Bailer test ppm,with_II.dnswdown alter_hrs,l
Air Lett 20 gptn with stem sat at 60 t1.for 1 hrs. JII Data 817/23
Artesian dow—gpnr
Temperature ofwatcr fit °F Was a chemical analysis made? ❑Yes Le]No Start Date 8/7/23 Completed Date 8/7/23
WELL,CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
constnlction standards.Materials used and the Information reported above are tnte to my best k»owledge and belief.
0 Driller O Trainee 0 PE—Print Name R e y P ythian Drilling Company Arcadia Drilling Inc,
Si nature / ..---- Address PO Box 1790
License No,2053 City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No, Contractor's
Sponsor's Signature Registration t'4o.ARCADDI098K1 • Date 8/7/23
ECY 050.1-20(Rev 09/13) Ifj ou need ibis document in an alternate fornrar,please call the Water Resources Program at 360.407-6872,
Persons with hearing loss can call 711 for Washington Relay Service. Persons Wilt a speech disability can call 877-833-6311.
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Thurston County Environmental Health .
412 Lilly Rd NE 6 Olympia,WA 98506 •
• 360$67-2631
_ _
113. .....COUNTY
, , ' COLIPORM BACTERIA ANALYSIS
Date Semple Collected Time Sample County 1.
Collected
1 cr7I o anti
_Month Day Year
Type of Water System(oheok only one•box) Private Household. r:
Q Oroup A ri 0rcup 13 Other
• Group A and Group B`Systems-Provide from Water Facilities Inventory(WFI): )
- p
Ib#
S'
yetem Name.
(
1
ContaotPerson: iao 8:
P 4 . Cell+Phone,( • .) r
•
Ray Phone(� ° / f
E mall �. :y t
e•.� P° Eve;Pfione , -: ')
Send results to(Print kilt name,address end zip a d or email address)
.e.:- - •
SAMPLE'INFOR1VIATiON
Sample CDII ots e. : .
.S apifle location or addreswhere aampta collected: Special irstructloneer coinntents;
map .. F . t
Type of Sample.(mustcheek;orily on box.of*I thraugltlf4•listed below)',
1. Routine.Distribution Sample
tj 2.Repeat Sample(after upset-routine)
i C.hlorinated:Yes • No .. 0 Distribution System •,
Chlorine Residual:Total Free .. Chlorinated:Yea._._r No
•3.Raw Water Source Sample-~^ • Chlorine Reeldual Total _Free
0.E.coil-'GWit(AfP)
. CI Fecal-surrace,owl,aprings(numeration). Unsatisfactory routine lab number : :f,
Filtered:Yes -_ No .::,;;.:.�., ._
•a Assessment Monitoring(AIP)- Unsatisfactory routine:collect date:
QOther . I. I s
S:
4; . .Sample Collected for information Only
lnvestlgative __ Construction I Repairs, .r, Other ;
SLAB USE ONLY DRINKINQ WATER RESULTS : LAB USE ONLY
�..___Unsatisfactory Total Collfarm.Presentsnd __
] Satisfactory Oll(o►m detected
0 E.collpresent 0 Exalt absent
• NO
Replacemi
. ent Sample Required:
1. . Q Sample too old(>30 hours) Q TNTC' 0.L_________
. f:
Bacterial Denelty Results Total Conform —..J100ml, E.CQII '_11001111
Fecal Celiforin • /100m1 Enter000ccl • /100 ml.
Method CodeN11M 92238 QSM 9222D Date and Time Recslvgd
. 0 SM 921513. 0 Enterolort® l _•1 "24 1:O1i
Date and Time Analyzed: Wx^'07-- Date Reported:, . p0•
a ample Number(DON number plus live digital h aOe9� fot.,01