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HomeMy WebLinkAboutWAT2026-00155 - WAT Application - 8/14/2026 WAT 2026-@0155 e ° I MASON COUNTY : .5 #.. a) COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6"'Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 ❖ Belfair:(360)275-4467 ext 400 Elma:(360)482-5269 ext 400 FAX(360)427-7787 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 an this application. Part 1: Applicant/ Parcel Identification Name on Applicant - Date: Mailing Address:4kD2p 4t ' Phone: ' ' i 4 1, i Parcel Number: Fj Z:r -}c' Type of Water System Reason for Application ❑ Public/Community Water System(2 or more Building permit connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL Well O Boundary line adjustment 0 Spring/surface water ❑ Other(explain) ❑ Other(explain) O Replacement or Remodel(please indicate name If you have more than one residence connected o₹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) 0 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. 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 o₹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:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth ft. >400 ® Well capacity Test(attached to application) gpm_ pd. 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA httD://Ois.co.mason.wa.uS/lJlaflfliflQ 14_15 16_22__ Water use or limitation recorded................................... N/A_____N/A Yes WellDrilled ............................................................... Date 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 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: 8/14/2026 Environ. Health: Date CSD Director: Date 2 of2 . 4l Parcel number corrected 11/20/24 WATER WELL REPORT _ DEPARTMENT OF Notice of intent No. WE56166 ECOLOGY Unique Ecology Well 11)Tag No 13O059 Type or Work State ottvashingtoo Site WellName(ifmorethan0neu+cll) Construction O Decommission c=,i Onginal irisrallation Not No. Water Right Peetnd/Certifcate No Propwcd Use: at Domestic ❑Inds stria) ❑Municipal Property Owiser Name Darrel Barnes ❑Dewatering O leaps tion ❑Test Well a Other Well Street Address 410 SE Sea Der Hok Ln Comt—ctionType: Method: City Shelton County Mason C7 New w Mien anon❑Ahat on O Dri.xn ❑)erred O Cable Tool D Deepen rig ❑ t O Dug to Air O stud-Roisly fax Parcel No. t%10 X22020 33 9W50 Dimensions: Diameter of boring 6 in.,to 220 R Was a variance approved for this.vela? O Yes fl No Depth ofcsmpleted well 219 R If yes.what was the variance for? Construction Details: Wall Cosiag Liner Diameter From To Thickness Steel PVC Welded Ttucad R I 06 in. 0 215 .25 in ❑r 1 O O I O Location(sne instructions on page 2)• ©W WM or❑EWM ❑ 1 ❑ ^in- _ _in. ❑ I I] ❑ I ❑ NW Y Y.of the NW '/;Section 29 Township 2 0N Range 2W I ❑ _in. _ _its DID DID Latitude(F—xample_4?.12345) 47.19976 ❑ 1 CI in. _in O1 O ❑ 1 ❑ Longitude(Example:-120-12345) -122.9&837 Perforation: O Yes la No Type ofpetforator used Dritler's Log/Construction or Demmtnission Procedure No.of perfuradons__ Size of perforations-to by_-is Formation:Describe by color,character,tire of material and structure,and the kind and Perforated from [L to it.below ground nd tuner o stature of the material in each laver penetrated,with at least one carry for each chnnge of Screens: El Ycs O No lil K-Packer r---' Depth 212 R informaation. Use additional sheds if neeemary_ Manufactemer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Brown sit sand and ravel 0 21 Diameter 50 Slot six-014 is fmm 214 fl.to 219 n. Brown sandy clay 2i 32 Diameter_ Sloe sim_in.from _ft.to-fi. 32 150 ueday der S Fd aud/ mr pack:❑Yes S Ne Size alpack trnteriat_in Gr Si ravel,wet 150 162 Materials placed&rim_11-to_fi Gra si sand 162 167 Surface Seal: 5)Yes O No To what depth?j n. Gray silty sand,Small gravel 167 190 Material used in scat Bentonite chips Gra sand,tteavi .water 190 220 Did any suau contain untaabk water" 0 Yes O No Type of water? Depth of siesta Method of scaling strata off Pump: ralanuracturefs Name Type: t(.P._ Pump intake depth: it. Designed flow rate._gpm \Pater Levels;Land-surface ckvation clew recess sea revel 110 fl. Stick-up of top of well casing j.,,_. above ground sea face Static water level 86 fi.below tap of welt casing Date 9/'30/24 Artesian pressure_lbs.per square inch Dar Artesian water is controlled by (cap,satin,nun.)-.---- - - Well Tells! Was a pumping test performed?El\o O Yes -_-D by whom? Yield_gpm with . R.drawdown after his Yield—gem wide—n drawdawn olive_Ins. yield_gpm with__n.dmwdown after—his. Recovery data(time=zero when pump is turned off—water lcvet measured Frosts well top to coated level) WWer Le.el Time Waler Level time Water Level Time Date oiptunping test_ rtailce rust gym wish__a drawdown slier hrs A r ten 30 gpm with stem set nl 180 0.for 1 his. Date 9130124 Artesian flow-ppm T'eniperalure of water 50 ^F u'as a chem aru ical lysis nude? ❑Yes 5 No Stott Dale 9125124 Completed Date 9130124 WELL CONSTRUCTIO`i CERTIFiCATION: (constructed nest/or accept responsibility for construction of this well,and its compliance with all Washingtnn ttdl construction standards.Materials used and the information reported above arc true to sty best knowledge and belief- F Driller D Trainee D PE—Pr e Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No.2874 City.State Zip Shelton WA 98584 IF TRAINEE Sprmsor's )cerise No. Contractor's $ nsor's Si r alure Reegistroi,on No ARCADD1098K1 })ate 9130/24 ECY 050-1.20(Rev OW 1 S) if yen/need this dot'tutietn in rat ahenwte forma[.please call lire(("islet Resources lrrogmm at 361J-4o7-f 872. Pei-soils with hearing toss can call 711 for Was/tinglon RelaySetvice. Persons mtth a speech disability can call 877-833-6341. Thurston County Environmental Health 412 Lilly Rd NE t Olympia,WA 98506 360 867-2631 TI1L:Rs1( " COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected o 811 12oz IDS oon D PM Month Day Year Type of Water System(check only one box) Privd`:e Household 0 Group A []Group 8 pot er� Group A and Group B Systems--Provide from Water Facilities Inventory(WF I): ID# System Name: Contact Person: Darr 4- 1errl r Day Phone:(?,O) . Z Cell Phone:( ] E-mail Eve.Phone:( Se d results 10:(Print ft 11nam-,address and zip codS 01 email address) krrA s f['R r Y1ES ii SAMPLE INFORMATION Sample collected by(name): 0 rrei •- r n e-5 Specific location or address where sa La collected: Special instructions or co nts- �k �� �y15fi? k F gg S 1 1 z Type of Sample(must check only one box of#1 through 04 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unset.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total—Free` Chlorinated:Yes No 3,Raw Water Source Sample Chlorine Residual:Total_Free ❑E.colt—GWR(AfP) ❑Fecal—Surraee,Gil springs Inumerauonl Unsatisfactory r. routine lab number Filtered:Yes_No _ V o Assessment Monitoring(NP) Unsatisfactory routine collect date: Dottier 4.❑sample Collected for Information Only Investigative_ Construction f Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Satisfactory ❑Unsatisfactory Total Colifamn Present and No CoI form detected ❑E-cols present ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) i]TNTC ❑ Bacterial Density Results:Total Coliform f10oml. E.coli 111}l]m1. Fecal Coliform 114Bml Enterococci /f00 ml. Method Code: Nl 9223B ❑SM 9222D an Time Received: eei 05101 5215B ❑Enterolert® 202 �° �Ll Reporte `Ii-2C s� pals aatl Time Analyz : ! ;, Sample Number SDOH-e per plus I cc J 015)•' Use Only: 0 8 a hi3Cg OOH Form#3331.315 revi p.,sed111231