HomeMy WebLinkAboutWAT2026-00008 - WAT Application - 2/27/2026 WAT 221 - 6 ,fie
rl N CCit N Y 415 N.6a'Street
Shelton,WA 98584
114 i4a1 t, Shelton:360-427-9670,Ext.400
•, � Public Health & Human Services Belfnir: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
� 1 r I. f d
Name on Applicant:` }') ' '(. t ` f}�iFF�L j Date: 1 ' t L O
Mailing Address: j; � f✓ (JdI•G t .>>I11✓4d . Phone: o�QZO • F •C (
Parcel Number: 19t) MC .()
Type of Water System Reason for Application
Public/Community Water System (2 or more )( Building permit
connections) 0 Division of land:
' ❑ Individual water source(one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
O Spring/surface water 0 Other(explain)
❑ 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. jl
; c .#LtL.j LLB , L.1 . Pah 62_,
Part 2: Water Connection Information I D.,61 i - 39, - 6)00 I 0
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 4
Water Facility Inventory(WFI)Number: non L. (write"none°for two-party)
❑ I am the manager of this water system.The water system has been approved for r services.There
are presently 1 connection(s)in use.This will be the r.. 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
MD Forms\Drinking Maier Revised 05/08/2024 Page I oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
• Individual Water Well
Water well report(attached to application). Depth 2"Z-Oft.
Well capacity Test(attached to application) gpm 06gpd.
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
❑ 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
S
Part 3: Mason County Community Services Evaluation (staff use only) -
\l 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.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
,Reeviewer's Signatures:
te Environ. Health: -7QI`'V��►Y "vi it Date /2-71?
This form may be scanned and available for public view at www.masoncountywa.gov
Page2 of 2
i
e• ` CURRENT§° WATER WELL REPORT
�. t1sfe+et&ip copy-EooBolliK2~rx>py-otraez, BAR
3H ooFy-teak r Notice of Intent No. W34b040
DrrAArpMT Or Unique Ballow Well ID Tag No. BAR12i
I4 Conatauct#oeJDeeommfsrifon("x"in circle) Water 11�-��Right PermitNo.
%r Construction
vI Decommission ORIGINAL INSTALLATION Property OwncrNemo_. Mlke_Ss
'�� Notice oJlntent Number Well Stud Address {�v' " F 7a Wt►son Pt RA
� ?Ronan Unit � Domestics D Industrial O Muesewal @Kasen
p nowater Cl it ❑Tcntvdl ❑Ma�-- City Shelton County®, zsti 0
Typ$t]1PWORLC: Dreamer'smmrbacofwett(if a+ora than onc) ioCatiprr t�el/4ll4 X1/4 Sec 1$ Two Rho! or
O '• Now welt O R0000ditloncd Method:0 Dog 0 Bored 0 0 fated (a,t,r Still REQUIRED) r ;
C0 nae> cable 0 Y
e DIMENSIONS&DimtKt of same @ ioobab dallod2 It
god win 2200. Lat/Long Let Deg
List Niin(Sec
0 CONSTRUCTION DETAILS Long DegLang Afi[I/Sec
e+"' Cha tea e+"' 0 Waldo! E* Dim.fium l ft a a0,ft ft. Tax Parcel No.(Required) t 1&3 X0010
.5- Iruta0odt 0 Linea Willed Dia+o•� fit°
" a Gam.From fL to ft.
faPo foratidn; Yes No CONBULUCTLON OR DECOMMISSION PROCEDURE
.ms Formstion:Describe by color,character,rrao of Material and aerueloro,and tho End God
0 Two of parfait=used oat=of the material In each Graham pmttraxd,with at lout a m army for NA change
m ft to_,_R.
O SIZE of tom...-m•by -.ia.and Qo.of Pte'_moo of information.(USE ADDCRONAL SHEETS.IFNECF.93ARY.}
1 Scream ® El Yea 0 No K- Laation �M TO
MATERIAL 0 18
Fa MnaofactumeaName Johnson Sandy Gravel tardbrotm
SWe a Model No. Fine nand 6 small omveitt,tan 19 158
td Dorm.Offlot adze a from 2IQ 1 b all rt Brown.
CI Diem. Shoe aim from ft to IL Sny sand,day lames with- 168 188
O Gravdll7bier tyekti:0 Yea El No Site of5r eUaard organics,dart brown 189 169
S Materials placedfront ft.t° Silty sand d,day,brown 169 210
Borfacc Seals 0 Yes 0 No To what depth aft. bled sand&taster,brown
C Malaita Gard is seat
IT Did 1. No
Wary shot wotaia unusable water? 0 ye*
A•" o of w$ th ofetr.L
01 1
Method of scaling etrate off
PUMP:Mmofrct rresNam®b Tip. si ? ---
te N.P. _� L
Z WATER LEVELS: Laradvurr000 elevation ab04ro mesa sea level fL +°7 1
I
N Starie level j.2O1.6dor top of w:dl Date
® an.Per square loch Date
Artesian pwuro 1 L>G
[sap valve,etc.) i�jill ,
'� Artesian water is controlled by � � -�.
9Fa ..+
�vELS.TPsfs Drastitbwa is amount melee level is towered below mode level mVit
O Wu a pump ten:otdo?❑Yea ®No Ifyas,bywhom7-_ ie l"" rn WO
AYtdd:^_�allpaia with_II.drawdovm aftera.te cCi rte-
f' ~Yadd:_sal/min.aicb .il rtnsidowv after g lu N ,
_too. W r� CI 4)
mie..rult.�_.�drawdovm ears g_ "1 < � r
W Yield:�ayJ Paned off)(raakrinzl mamma from ,
aa�+ Rrro+rye#,tr(<tea��'oamrurhmpur�
O Wit top so troies krrq
- rtmo Victor Lard Ilmo Waterteval Time Water Leval p
,
( Deaoftest 53-11
isSe;tcr 1.018 gatJmio.with 2t1_ft 6sardax,sstar'.tas.: `
yi Airtmt_JO/mixt with Mom MA at it:for bro.
CP n isa now gym-Disc Start Date 4-12-11 Completed Date 5-3-11
7'ap,pcnm,ro of wator Was a chamic.►l analysis made? ❑ Yee O No
l"' se r
[ICIION Milt I constructed and/or accept teaponlibility for cooatruetion of this well,end its compliance with
tactth'ell Washington wen s
• WEt Ratandards.Materiels used end the information reported above arc tree to my best lmowledge and
a. 11 Engineer Li Trainee Name Ow)Dwane H Knapp Drilling' Company KNAPP DRILLING INC
D illeriEn8inecri'Frrmee Signature Address 5013 Leseca Drive
1706 City,State,Zip Shelton , Wa..98584
Aailleror trainee Lamm Na Contractor's D11tAINER:D Uer'r eNo: Contr ctornt3o.KNRFPa195281 Date OS 17-11
Dares .� r,..w „,e4-toys
ECY 050-1-20(Rev02/10) If}ou need rids document in an atarnate formal please call the Wafer Amara.;Program at 360-074871.
Persons with hearing loss can call 711 for Washington RelayServla. Persons with o speech disability arts col 1877-833-6341.
3
p �
Prig' d F -2-0-1-1--a32'.1'740
t a
2:O.1.1-=3`2_ `BOO to
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Dave Rossi Well Tag#: BAR121
Site Address: 193 E Point Wilson Rd,Shelton Depth:220'
Date of Test 1/29/26 Static: 170'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY # , j ¢'
1 Min 20 175.3 TIME LEVEL „) '`I :, g`
2 Min 20 177.7 1 Min 171.7 "-t. ''' ,
3 Min 20 178.7 2 Min 168.9 - '
4 Min 20 179 3 Min 167.9
5 Min 20 179.2 4 Min 167.5
6 Min 20 179.3 5 Min 167.3
7 Min 20 179.4 6 Min 167.2
8 Min 20 179.4 7 Min 167.2
9 Min 20 179.4 8 Min 167.2
10 Min 20 179.4 9 Min 167.15
15 Min 20 179.5 10 Min 167.1
20 Min 20 179.5 11 Min 167.1
25 Min 20 179.5 12 Min 167.05
30 Min 20 179.55 13 Min 167.05
35 Min 20 179.55 14 Min 167.05
40 Min 20 179.66 15 Min 167
Total Gallons Pumped: 800 Gallons
Thurston County Environmental Health ',
412 Lilly Rd NE z5 Olympia,WA 98506 j
► '� 360 867-2631
•
CHUPSTO1 COUNTY
COLIFORM BACTERIA ANALYSIS
County
Date Sample Collected lime Sampleed '
t ° . .f 5o
Verdi Day Yeas 1� Pryat 1��
Type of Water System(check only box)
0 Group A 0 Group B t, Other
Group A and Group B Systems—Provide from Water Facililles Inventory(WFt):
_L-
System Name: .� �n!� s 1
Contact Person:
ttra0 c�rt„, Cell Phone:( �228.r�gs'r
Day Phone.( ) o
t a F(+6irt4 Pr il.1.C.f. ve,Phone:( )
E-mail: �,1�5�i �
Serf restrus ro:(Print ame,address and zip code or emaa address) i
SAMPLE INFORMATION
Sample collected by(name): .•.J i� R(1.5,,;\E
I
Specific location or address where sa 'e collected: Special instructions or comments:
y� 03 c retrr-
ti75� LJttti.�aor)
Type of Sample(must check only one box of d1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat routine)
Chlorinated:Yes No ❑.Distribution System
Chlorinated:Yes No
Chlorine Residua{:Total Free �
3.Raw Water Source Sample Chlorine Residual:Total•_.__Free —
{
❑E.colt—GWR(A/P)
❑Fecal—surrava.cvra,spills(ou'cera.ly Unsatisfactory routine lab number. I
Filtered:Yes___t+o_— `———--— ——
❑Assessment Monitoring(N Unsatisfactory routine collect date:
❑other i—____I
,
Isi
4.❑Sample Collected for Information Only
investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY l
�Satistactory `
O Unsatisfactory Total CalifonPresent end No Coiitorm detected
CIE.cu;ipresent ❑E.colabsent
Replacement Sample Required:
❑Semple too old(>30 hours) ❑TNTC ❑ -
Bacterial Density Results:Total Coliform
/100mi. E.coli /100ml, i
Fecal Coliform 1100n11 Enierocaccl /100 nil, G
Method Code SM 92230 OSM 92220 Date and Time Receivadi 4-•f
SM 92150 0 Enteroleri® l,'11*t'' Vitt( I
Dale and Tess Anal ed: Date Repoded I•/2.,,,,..1-,Z f''
Lab UsePab.
gyzy';lturtbw{DDii rtmYtOtu sfaedryUsj �"
° 8 ° :, C
I
DOH Fern op•319(rzr red 111231
1 2-Ci .c t