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HomeMy WebLinkAboutWAT2026-00093 - WAT Application - 5/28/2026 WAT 2026-00093 415 N.60'Street MASON COUNTY Shelton,WA 98584 i • COMMUNITY SERVICES Shelton:360-427-9670,Ex..400 I3elfair.360-275-4467,Ext.400 Building,Planning,Environmental Health.Community Health Elora:360-482-5269,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 on Applicant: 5J oL& Date: L Mailing Address: �3 6 13 i!f&off 4DL ft Phone: 3(o 5€/ 0 g Parcel Number: 5 1& -f 5O Type of Water System Reason for Application ❑ Public/Community Water System (2 or more �. Building permit connections) O Division of land: Individual water source (one connection), #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(WFl) Number: (write"none"for two-party) O l 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. O 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\FH Forms\Drinking Water Revised 414x'2018 Individual Water Well Water well report(attached to application). Depth 72 ft. Well capacity Test(attached to application) 30 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. Ii;l Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA htto:/Lctis.co.mason.wa.us/plannini 14_15.. .16_22X Water use or limitation recorded................................... N/A_____ N/A Yes Well Drilled ..............................................._............... Date '/3o(ZO Individual Spring/Surface Water D WDOE permit(attach to application) O Method of disinfection O 1 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) Rl 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). Reviewer's Signatures: tl-�l 5/28/26 Environ. Health: Date This form may be scanned and available for public view at veww.co.mason.wa.us. Page 2 of 2 WATER WELL REPORT �i _ " D'EPARTiViENT Or Notice of Intent No. W316941 ECOLOGY Unique Ecology Weil ID TagNo. BJT 965 Type of Work: State of Washington IJ Constktwtioa. Site Well Name(if more than one well): El Decommission ' Original installation NOt O. Water Right Permit/Certificate No. PropoBedThe: LI Domestic D industrial O Municipal Property Owner Name Kathryn&Donald Skolrod 13 Dowatering O irrigation O Test Well ❑Other Well Street Address 331 W NahwetzQl Beach Drive Construction Type: Method: Iel Newwwell CiAltemtion O Driven Cl Jetted 17 Cable Toot City Shelton. County.Mason o Deepening ❑Other Cl Dag 13 Air- ❑Mud-Rotary Tax Parcel No. 52004-50-00029 Dimensions:Diameter ofhoring 6 in.,to_it Was a variance approved for this well? 0 Yes No Depth of completed well 72 1t. If yes,what was the variance for? Construationfletails: O✓au Casing Liner Diameter From To Thickness Steel PVC Welded Thread >a i ❑ 6 in. +2 72 .025 in. I1 I E3 © i Q Location(see instructions on page 2) • J O VJWM or❑EW14I O 1 El in. __ in. ❑ i O O I '❑ sw '/4-'/,of the SW %;Section Township 20 Range 0lj 5 ❑ 1 ❑ — _ in. ❑ El ❑ I ❑ Latitude(Example:4712345)47 24587 +s Longitude(Example:-120.12345)123)3AO403 0 Perforations: ❑Yes I No Type ofperforatorused }?rlUer+a LoglConsiruct#gt� AeeotnrnlssiotrPracedtare No.of perforations Size ofperforatiens in by tn. Formation:Describe by color,charade,sii'1 terial a id structure,and the kind and Perforated from It.to It.below ground surface nature of the material in each layer pcnetncIdh attett one entry for each change of Information Use additional sheets ifneceas 3 Screens: El Yes Cal No Cl K-Parker Depth ft. Maoufaeturer'sName Material_ _____ From. To C Type Model No. 0 3 t]iamatcr.. in. Slotsizc in.from ft to ft Brown Top soil with gravels Diameter in, 5lotaize In.from it.to ft. Brown Glacial Till with cobbles 3 23 Silt.Bound sand&Gravel with seapage 23 25 SandlFilter pack:O Yes 19 No Size.of pack material in.�: Brown Till 25 36 Matcnals pTttceti from ft.to ft. Sift Bound sand&Gravel 36 47 Surface Scab 91 Yes CI No To what depthl 18 it. Brown fine silty Gay 47 50 Material used in scat Bentonito Chips sand gravel&water 50 72 Did any strata contain unusable:water? D Yes 9 No 72 85 Type ofwatp7 Depth,fstruta Black basalt 72 92 Method of sealing strata off BLOWN/Otter basalt 55 is Pump:ManufactoreesName Franklin Type:Submersible pump intnke lepth 65 :fr. Designedllow rate:10 gpm �; Water Levels/Laiid-sorfae elevation shove mean sea level 480.It. Stick-up aftop of well casing *2 ft.above ground surface Static water level 18 IL below top.ofweli casing Date 6127120 Artesian pressiue lbs.pet square inch Date Artesianwater Is controlled by (cap,valve,etc.) 3 Wen Tests: Was a pumping test performed? IB No ❑Yes b by whom? c n . --L 9. Yield gpm with^,_.ft.drawdown after hrs. Yield . .gpm with_ ft.drawdown after hrs. oYield . gpmwith ___R drawdownafter hrs, i Itnvl t7 Recovery data(time—=to vncCnpump is turned off—water level measured from well L' top to water level) Time Waterievel Tine }VaterLevel Time Water Level ci i iegoi.trcF 3 5-To juirn u o _ Date of pumping test. Bailer test 0 gpni withl 2 ft.drawdown after`}his.___Air tea! ,gpm with stem set at ft.for hrs. hDataO8/27/20' L Artesian Clow gpm yTempeiiitttrc of water. ."F Was a chemical analysis made? O Yes 19 No Stait Date 08/24/20 Completed Date 08/30/20 D WELL CONSTRUCTION CERTIFICATION: I conshucted and/or accept responsibility for constriction of this well,and its compliance with all Washington well eonstniction standards.Materials used and the information reported above are true to ttty best knowledge and belief 0 Driller❑Trainee❑PE—Print Name Dwane H Knapp Drilling Company Knapp Drilling Inc Signature tw lrI •' lJ Address 50 E'Lesaca Drive LicenseNo. 1706 City,State,Zip Shelton,Wa;88584-7001 iF TRAINEE:Sponsor's LicenseNo. Contractor's Sponsor's Signature -Registration No_KnappD1952B1 _ Date 08/08/20 ECY 050-1-20(Rev 08/19)Ifyoa need this document in an alternate forrna4 please call the Water ResouncesProgram at 360-407-6872. Persons with hearing loss can call 713 fur Washington.Relay Service. Persons with a speech disability can call 877-833-6341. ruin+ rr Ø1U %olvUlr w !Vviuc UUVWWW vYO(c1 I avIfltfva uu1vv!1Lv!y kvvl . ID System Name or Address: H Contact.Person: re'"6 Day/Cell Phone`. ( "` Eve. Phone: t' C0 '" Email: ¢ e r!2 Send results to (Pant full name, address a d.zip code) 3c ► • ' iiiiiiii — Hzv tf4 _____ SAMPLE INFORMATION Sample collected by (name): . S I .Specific location where.sample cóllected I Special instructions or comments: 33 / _____________ cincA- Type of Sample (must chest only one box of#1 through #5 listed belo r.Private check #5.) I w El Routine Distribution Sample (NP) 2. Repeat Sample (AIP) Chlorinated: Yes No (from distribution system after unsat. routine) Chlorine Residual: Total Free Unsatisfactory routine lab number: 3. S:purce,Ground Water Rule Sample s Unsatisfactory routine collect date: I El Triggered CA/P) Chlorinated: Yes No a Assessment (ASP) Chlorine Residual.Total Free 4. Surface or G I Raw Source-Water Sample (Enumeration) LS O E..cOll ®.Fecal-•Surface, GO, Springs: Filtered: Yes No_ 5. Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS USE ONLY I'-1 tJnsatrsfactory Total Coliform Present and I Satisfactory