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HomeMy WebLinkAboutWAT2026-00150 - WAT Application WAT 2026-00i 50 • MASON COUNT 415 N.6d'Street Shelton,WA 98584 Public Health & Human Services Shelton:360-427-9670,Ext_400 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/ Parcel Identification / Name of Applicant: AJCx nder L%hcrtin__ Date: 6//7/ D Mailing Address: 1293 NW Amanda Loop Silverdale,WA 98383 Phone: 360-Sol-5310 Parcel Number: 122052190072 Type of Water System Reason for Application C Public/Community Water System (2 or more ,1 Building permit BLD2026-00569 connections) ❑ Division of land: El Individual water source (one connection), #of Parcels? SPL ❑ Well El Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) El Other(explain) ❑ 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. See WEL2026-00022 Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluate& Public Water System Name of Water System- Water Facility Inventory(WFI) Number: JCr/\e (write"none"for two-party) I am the manager of this water system. The water system has been approved for a services. There are presently a connection(s) in use.This will be the a? connection. El 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 _ k' s i'1 in ' Phone 3ofO� la(oa 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 WATER WELL REPORT DEPARTMENT OF Notice of latent No. WE46802 ECOLOGY Unique Ecology Well ID Tag No. BNV900 Type of Work: State of Washington C7 Construction Site Well Name(if more than one well): ❑ Decommission = OriginaliaatallationNOlNo. Water Right PermitlCertificateNo. Proposed Use: Ial Domestic ❑Industrial ❑Municipal Property Owner Name Kris Kl sman ❑Dewatering O Irrigation ❑Test Well ❑Other Well Street Address NE Alder Creek Lane Construction Type: Method; El New well O Alteration O Driven ❑Jetted ❑Cable Tool City Belfair County Mason O Deepening ❑Other ❑Dug Ii]Air- ❑Mud-Rotary Tax Parcel No. 12205-21-90073 Dimensions: Diameter of boring 6 in.,to 100 R Was a variance approved for this well? 1]Yes D No Depth of completed well 99 R Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread L9 I ❑ 6 in. 0 78 •.026 in. [ O O I O Location(see instructions on page 2): [WWM or❑EWM El I U m. _ - in. ❑ I O O I O NE y.-y,of the NW �/;Section 5 Township 22N Range i W DID in. _ in. ❑ I ❑ DID ❑ I ❑ in. in_ El I O O I O Latitude(Example:47.12345) 47.431693 Longitude(Example:-120.12345) -122.834225 Perforations: O Yea to No Type ofperforator used No.ofperforations Size of perforations is by in Driller's Log/Construction or Decommission Procedure Perforated from ft to_R below ground surface Formation:Describe by color,character,size ofmaterial and structure,and the kind and nature of the materiel in each layer penetrated,with at least one entry foe-each change of Screens: ❑a Yes 17 No ]K-Packer ) Depth 76 R information. Use additional sheets ifneeessary. Manufacturer's Name Johnson Screen Material From To Type Wire Wrapped Model No. Diameter 5 Slot size.008 in.from 78 ft to 88 ft Fine sandy ravel,silt bound,tight,dry 0 53 Diameter^ Slot size in.from A to R. Fine sandy dayee silt,dry 53 79 Sand/Filter pack:❑Yes i l No Size of pack material in._ Fine brown sand,water 79 94 Materials placed from ft.to ft. Brown da ee slit,dry 94 100 Surface Seal: i]Yes O No To what depth? 20 ft Material used it seal Bentonite ChIps Did any strata contain unusable water? ❑Yes U No Type of watce? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: lIP. Pump intake depth: R Designed flow rate: gpm Water Levels: land-surface elevation above mean sea level ft. Stick-up of top of well casing.......:L..ft.above ground surface Static water level 64 ft.below top of well easing Date 3/14122 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? l No O Yes by whom? Yield gpm with_ft drawdown after bra. Yield gpm with_ft.drawdown after hrs. Yield gpmwith_ft drawdown after lire. Recovery data(time—zero when pump is turned off—water level measured from well top to water level) Time Water level Time Water Level Time Water Level Date of pumping test Bailer test gpm with—ft drawdowo after_his.} Air test 5 gpmwith stem set at 80 R.for 1 bra. Date 3114122 Artesian Ilow spm Temperature of water 'F Was a chemical analysis made? ❑Yes ]No Start Date 3/14122 Completed Date 3114/22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. l7 Driller O Trainee❑PE—Print Nam a hythlan Drilling Company Arcadia Drilling Inc. Si afore Address PO Box 1790 License No. 2053 City.State,Zip Shelton,WA 98584 liP TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 3114122 ECY 050-1-20(Rev 09/18) Ifyou need this document in an alternate formal,please call the Water Resources Program at 360.407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833.6341. 26276 Twelve Trees Ln NW Stec f --SPEC'I'RA Lahoratories Kithap Poulsbo,WA Where et ereence mat7ers 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 7 / I Z5 Collected ❑nM Month Day Year :1® XPM Type of Water System(check only one box) ❑Group A ❑Group B , Other r' eT I�etl Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: Li 4i1-' Day Phone: / rJ fQ Cell Phone: 960 fo/ x0 Email: e rY1C©i@/Io .Co Send re s to:(Print full name,address and z code) ` g52 SAMPLE INFORMATION Sample collected by(name): J 7 Loeo/h Specific location where sample collected: I Special instructions or comments: £/o 41.6Aldei c eK LN ®t.;r v2 995Z .. H"3e ; G T Type of Sample(check only one box) 1.❑Routine Distribution Sample(NP) 2.❑Repeat Sample(NP) Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine) • Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample ——— — S Unsatisfactory routine collect date: / I Chlorinated:Yes No ❑Triggered (NP) Chlorine Residual:Total Free ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) ❑ E.coli 0 Feral Filtered Yes_No 5.i J Sample Collected for Information Only: Pdvate Residence f Cons6udionI Repairs LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and S.ttisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform mpn/10oml.E.coli mpn1100ml. Fecal Coliform cful100ml. HPC cful1 ml. Replacement Sample Required: El TNTC ❑Sample too old 0 Sample Volume 0 Damaged Container ❑ Date. eceived: Lab Reference Number �0 - Receipt Temp C. Method Code SM922 QT-COUNT/SM9222D This report is issued solely for the use o1 the person or company to Date In: Date Out: whom it is addressed.Any use,copying or 5sotosure other than by the 7777 intended redoent is unaudwrized.U you have received this report in _ error,Please nobly Lhe sender immedialey at 360.779.5141 and DOH Lab—Sample# destroy this report promptly. O O These recurs relate only to the terra sated and the sample(a)as 010 received by the laboratory.This report shall not be reproduced except in full without prior express written approval by Spectra laboratories. DOHFonn#331.319(efleclive 0N17) C.4`t.e ?1Q"l'1 7"'/(,.