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HomeMy WebLinkAboutWAT2026-00015 - WAT Application WAT 2O2( - MASON COUNTY _....0 '' ' COMMUNITY DEVELOPMENT 2 t} Permit Assistance Center,Suirilink,Pi JAN srining 3 2025 415 N 6th Street,Bldg 8;Shelton WA 98584, Shelton:(360)427-9670 ext 400 ❖ Belfair.(360)275-4467 ext 400 fi t lms:(360)482-526 Alder Street FAX(360)427-7,787 Application for Determination of Water Adequacy Instructions 1 Complete Part 1 :No determination can be'made until Part 1 i fully completed i 2 ;Complete only the portion of Part 2 applying to the type of water connection utilized 3 : Submit completed application,with any requited attachments for review. 4. 'An approved building.site lan must accoin an thisa " lication: Part 1: Applicant/Parcel Identification / Name on.Applicant:W,!M4 f-'' /t/{t)/V f4M( Date: Mailing Address: f 47 N ,Et ?/'1yc •�=R �t ldne: d(, s' Parcel Number: /2/19 7 lob t j Type of Water System /'Reason for Application ICI Public/Community Water System(2 or more ! Building permit BLD2026-00071 ,9onnectlons) ❑ Division of land: Individual w�r source(one connection), #of Parcels? SPL 1 Well ❑ Boundary line adjustment' Q Spring/surface water O Other(explain) El 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. Part 2: Water Connection Information Complete theaection appropriate for the type of water connection being evaluated: wrl �4J V Public Water System `� 00011. Name of Water System: Vow i'f'. 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 2servIces. There are presently ,_connection(s)in use.This will be the. Z _connection. 0 1 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 ofthis 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 a iimi set by sta and local regulation. Signature of Water System Manage. Date This form may be scanned and available for public view at www.co.mason.wa.us. 7:3EH Pormsl Drinling Water Revised 1/25/2018 S3 t!j Individual Water Well Waterwell report(attached to application). Depth Z_ ft. 6 rlr� Well capacity Test(attached to application) /tf gpm e>SO� gpd. t The well driller often performs wail capacity tests at the tirne'the well is cortstruoted, Results from these tests are noted on the water well report. Results from these tests will be accepted.If the water welt report-cannot be located by the applicant or if the water well report does not have aacapacity test, a well capacity test,which provides stabilization of draw down and recovery data,must be performed l i by a licensed contractor, Satisfactory bacteriological test(attach to application)., ! f Vtlatei`Resource Invoi'fory Area(WRIA} Dgvelopinetttwithinwhich WRtA http:i/gis.co,mason;Wa.us/ iennina 1 (1ti[=j 16cJ ≥2jj Water use or limitation recorded..................................... N/A _Yes: Well Drilled . Date Individual SpringfSurface•Water ❑ WDOE permit(attach to application) ❑ Method of disinfection U 1 have reason to believe that this water source can provide st least 8800 gattons per day;and/or provides waterat a•rate.of'2 gallons per minute based on the following observations, - l Author of Statement Date Relationship to Applicant ' S Paet.3: Mason Comity Community Services Evaluation (staff use only) r �.e^ 9c .' s F e`" 9 i -s t Sa rsfactor peterminatlont- y ° t� fihis etermfnailon iaes'no dre s a uac of a dlstd utlo_system, ua�ah ee an do eq ate sup of f { d9 y ft? py}' 9 t .w supply 7 }, fl water indefinitelylb the future,or guarantee cotnpiiar}ce°With all appticabte WDOE water resource regulatlois _ Reconjmehcded approval indicates reliultethipts of Sanitary Code;Title 6 Chapter 6 69 Q44 Determination of l l se; Adequacy forOudding Permits are saris fed Additional Growth Management requ(remepts may a pfy hpp er'3 l t 4 es+ .ter �+ r Gr 37r3�RGW} s � rte. ;�' "' #ti � ,_} t a �a< -rr 1} i. €,� r`� r e +. a £ u• r' �, r } f ri "G• i, i'- D UnsatisfactoryDetettriinatlon z Applicants water supply doeii not appear adequate to meet the needs of its intenclad Oise for the following s �` r•iiY -'� j _ t R� s �v fq>pp i .1+�'C'."y`�' r.s ,�... �. .� .; ._y ,:�• _ is i£-v.. ,:.. +.-� g: evIevper's Sig natut s' ^t J;[5nvfrort-'el Health ifc$ u.afiFLL 10 QJ IX {l7 E ? Y ; L/aLQ `'t5t0 h 226 3 'i _ �• CSD©tractor S�, date rof2 start card No. R '061313 JI WATER WELL RERORT UNIQUEWELLI.D.N 8 ---, r�rtptn+it and,FII 0109Y Cop a+xrS� trtment of Ecdogy rtd py —' "popy STATE OF WASHINGTON Water Wren:psm It No. ld t y:oditeea copy Bill VoiQht r PO Box 289 Gra eview . WA 98546 OWNER. N 21 N „n 1-W wr t, LOCATM OF WELL: C 01y Mason -SEj!4_ 1_tr,see t. 6 sTREEErao�RrssoFWL4f«r } E Lambard Rd Gra eve! WA 9854 iredupiriaf O Mdrticipat (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION 1 PROPOSED USE: Domestic. b color,character,.aae Oi material end structure,end show Ihorte ass of for each n- iftation Test Well O Other O Formation Dexribe.x ❑ Do Water end the kind ufd nature of the malarial In each stratum penetrated;with at least one entry each change of wonnatbn. TYPE OF WORK: owne number atollMATEFUj►L. FRrs►t TQ (if more than one) Method:Dug❑ Bored Abandoned O Nepene d O m Cab: O Driven❑ W C Deepened Rotary D Jolted Recorxlltioned O d O j 8 30 Inches. Brown sand DIMENSIONS S�:�� Diameter of well Rled f00t Depth of cornptotod wail 7 ft..12 CONSTRUCTION'DETAILSCa : ft Diem.ftom1f•%--1 7 Weed Installed: ` __ � n,tom^ aye r _ Welded. C( Di2rtt.from Uner installed U Diem-from n:ta`— Threaded` D pertprallo6s: Yes U No LX Type of perforator used in. SIZE of perforations in.by pertorationafrom n to ' '— ft.to fl. perforations from ______ ________________ fl.to ft• perforations from Screens: Yes[ No❑ Manufacturers Name `rt. $t n1 $ wire Wrap _Model No. S q7� p !1 Slot 1rom`_i su_—H.to_s[s._—tb Diem.—$IOi stzo -frem n.tom— fL Gravel packed: Yes❑ No Size at gravel Gravel placed from It.to Surface ssai; Yes s No❑ To what depth? ft, Material used Inset Did anystratacontafn unusable water? Yes❑ No Type of walor? Depth ofstlata Method of seallng strata 7) PUMP.: ManutaetwePs Name G r and f O S Type. H.P. Work started 1J' � 5 t9,� • 9 5• .l9. Cortwtetod.�/2 9/ . WATER LEVELS: iand:sudaeeelevetbn ft. ) 1 e mom Bea levei Static level It.balowtopeiwed Date-- WELL CONSTRUCTOR CERTIFICATION: fs,par aquefe inch Date__-- i,. �uteslanlxessura i constructed andlor accept responsibility for construction of this:wall,and its Arteafanwator,ls controtieeby v compliance with all Washington well cansiruction.standarils Materials used and tho information reported above are true to my best knowledge and belief• 0) WELL TESTS: Drawdown Is amount water level Is lowered helowstatic toyer Davis D r i 1 Ti s t�la a pump test mado?Yos 0 No if yes,by wttom?!�— NAME 1pE ;r otz txln Trar+l I Wa gal./min.iviCt ft.drawdown anar n Address rr �+ (Signed) r Utaotts9 No 1 R Rocaverydata(Brte taken'as:zero whenpump turned ol)(water io vet measured from►yell i °R lop toweter level) Water Level Time, Water Level Contractor's Time Water Level Time Regj�Va�fy U it 1X195 .te__ No,UAV $ )T1_400A Date (USE ADDITIONAL SHEETS IF NECESSARY) Date of test Sailer Eost 12'. /min;with .10 n e °""ear —-- Ecology is an Equal Opportunity and Affirmative Action•employer.For spa i ti_ " yQaLlm]n write 5QKRrsfrrt at,�-=.IL li I , , ,." , s clot accommodation needs,contact the Water Resources program at(206) l r m`�X7,6600.The TDD number is(206)407-6006. 7 bt(o of wat`�i t`rl wri 9Y4r, ! 'nary s ,,y?i l $S P raj Arcadia Drilling Inc. P.O.Box.1790 Shelton,WA.98584 Customer:James Morrison Well Tag#:ABG082 Site Address:260 E Lombard Rd S,Grapeview Depth: 172' Date of Test: 3/31/26 Static:130' Pump Set:,Unknown , TIME GPM LEVEL RECOVERY I Min 11 126.5 TIME LEVEL 2 Min 11 126.5 1 Min 122 3 Min 11 126.6 2 Min 121.2 4 Min 11 126.6 3 Min 120.8 5 Min 11 126.6 4 Min 120.7 6 Min 11 126.6. 5 Min 120.6 7 Min 11 126.6 6 Min 120.5 8 Min 11 126.6. 9 Min 11 126:6 10 Min 11 126.6 15 Min 11 126.6 20 Min 11 1266 25 Min 11 126.6 30 Min 11 126.6 35 Min 11 126.6 40 Min 11 126.6 45 Min 11 1.26.6 50 Min 11 126.6 55 Min 11 126.6 1 Hr 11 126:6 1 Hr 10 Min 11 126.6 1 Hr.20 Min 11 126.6 Total.'Galions Pumped:.880 gallons 3 Thwrston County Environmental Health 412 Lilly Rd NE b Olympia,WA 98506 rittnt;roty cours' 36O 867-2631 COLIFORM BACTERIA ANALYSIS Date Sample Cot(scted. Time Sample County Colbcted Mcern Day vea: e'' O Pll z Type of Water System(check only one box) Q Private Household 0 Group A ❑Group B 0 Other_ Group A and Group.8 Systems—Provide from Water acIBlies Inventory(WFI): lD## System Name: Contact Person x ,, Day Phone(r x< ) - Ceti Phone (: ) :§r E-maf, , ¢ r „ ) Send restdts to:tPrhel fuT name,address and rip code ar emal adders) SAMPLE INFORMATION •Sample collected by(name) '�'a ° :`�✓� ,'%;'° to �' r F101EC0#—GWR,(A1P) ocation or address where sample collected: Special Instructions or comments: ample(must check only one boil of 91 through#4 listed below) tine Distilbution sample. 2.RepeatSample(after unsat,routine) ated:Yes No 0 blslnbutron System Residual:Total.FreoChlorinated:Yes-" Noater Source.Sample Chlorine Res duak Total Free_ l#-GWR(A1P)l—sutra e,civi sprcrg3(rrararalo Unsatisfactory routine lab number. Filtered;Yes,;N'o O Assessment Monitoring(NP) Unsatisraclotyroutne collect date: DOlher S 40 Sample Collected for Information Only Investigative- Construction).Repairs Other => 1.- LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑f Unsatisfactory>Total Coliform Present and Q;Satlsfeclory ❑Ecollpresent ❑E cell absent, No Colitorm detected Replacement.Sample Required: El Sample too old(>30 hours) p TNTC [] Bacterial Density Rosuits;Total Colitor±n . JlOgmt: E coil /100mt. Fecal Qotifotm lit)nit Enteracocst 11Q0 ml. Method.Code:Q SM 92238 DSM 92228 Da±e and Tune Receve3:_ ,' (l SM.92158 ❑Enterolerl I Daleand Ti y M yzed:) t D&e Roponed $ a OOflvunierprsrved4) lab Use Only: xiiamH331-319ireo`seditr23) � €.