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Home My WebLink AboutWAT Application - 7/11/2023 D k t Via6-3,6Q- . WAT - lt_ U vin-r � � MASON COUNTY 415,WA6th Street z Shelton, 98584 a COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 l''°`'fn� Belfair:360-275-4467,Ext 400 ` p : `-`^S Baring,Planning.Envy' Health,Community Health Elma•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: ai.k\ 0.1ha`e— Date: 7 1l 0�3 Mailing Address: 6a( �j 0-itir E. Phone: 3L q—37SLJ Olywtpw, t.J►4 0l 5 1 Parcel Number: `iat 3s SD— 44>a5-3 Type of Water System Reason for Application 0 Public/Community Water System (2 or more A. Building permit 14 2cs2.3 oc51Sy connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ 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. 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) ❑ 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. ❑ 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.co.mason.wa.us. J:\EH Fonns\Drinking Water Revised 4/27/2021 WATER WELL REPORT ) DEPARTMENT OF Notice of Intent No. WE49076 t ut k ECOLOGY Unique Ecology Well ID Tag No. BNX260 Type of Work: W State of Washington t l Construction Site Well Name(if more than one well): 0 Decommission r•-: Onginal installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic ❑Industrial 0 Municipal Property Owner Name Bill Yandle 0 Dewatenng ❑Irrigation 0 Test Well 0 Other Well Street Address 860 Clear Lake Dr Construction Type: Method: ID New well 0 Alteration 0 Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening ❑Other 0 Dug lia Air- D Mud-Rotary Tax Parcel No. 42135-50-00053 Dimensions: Diameter of boring 6 in.,to 175 ft ! Was a variance approved for this well? 0 Yes IE No Depth of completed well 175 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread IE I 0 6 in. 0 171 .025 in. C§ I ❑ O I ❑ Location(see instructions on page 2): 0 WWM or❑EWM 1 ❑ I D in. _ in. ❑ I ❑ D I ❑ NW V.,-V.of the SW '/.;Section 35 Township 21N Range 4W ❑ I D in. _ in. ❑ I ❑ D I ❑0 I ❑ in. _ _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.265070 Longitude(Example:-120.12345) -123.161893 Perforations: 0 Yes il No Type of perforator used r No.of perforations Size of perforations_in.by is Driller s Log/Construction or Decommission Procedure Perforated from R.to fl.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: li)Yes ❑No )K-Packer 1==> Depth 169 R. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless Slotted Model No. Diameter 5" Slot size.018 in.from 170 ft.to 175 ft, Brown silty sand and gravel,loose 0 5 Diameter Slot size in.fiont fl.to_ft. Mulitcolored dean gravel,loose 5 15 Borwn silty sand and gravel 15 43 Sand/Filter pack:0 Yes El No Size of pack material in. Multicolored gravel,medium brown sand,loose 43 48 Materials placed from ft.to fl. Mulitcolored sharp gravel,fine brown sand, 48 Surface Seal: Id Yes 0 No To what depth? 18 ft. silt,tight 63 Material used in seal Brown siltbound sand and gravel 63 94 Did any strata contain unusable water'? 0 Yes ElNo Type of water? Depth of strata Multicolored gravel,coarse brown sand 94 150 Method of sealing strata off Multicolored gravel,coarse brown sand,loose, 150 water 175 Pump: Manufacturer's Name Type: 11.P. Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 370 ft. Stick-up of top of well casing 1 fl.above ground surface Static water level 110 fl.below top of well casing Date 9/12/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? l)No ❑Yes , > by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time-zero when pump is turned off-water level measured from well top to water level) Time Water level 'line Water Level Time Water level Date of pumping test Bailer test gpm with_It drawdown after hrs. Air test 30 gpm with stem set at 160 ft.for 1 hrs. Date 9/12/22 Artesian flow gpm Temperature of water 50 °F Was a chemical analysis made? 0 Yes El No Start Date 9/12/22 Completed Date 9/12/22 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. O Driller 0 Trainee❑PE-Print N e Josh Koepp Drilling Company Arcadia Drilling Inc. Si lure Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 9/12/22 ECY 050-1-20(Rev 09/18) If you need this document in an ahernate format,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. r' I 1786 SE Mile Hill Drive Port Orchard,WA 9E366 i! SPECTRA Laboratories_Kitsap www.spectra-lab.com _.,e..eamraw.e.n (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 9 1 20 / 22 s rim Mason aka& oar Year •--®pu Type of Water Sy lem(check only one box) ❑Group A ❑Group B DOfher Group A and Group B Systems-Provide horn Water Facilites Inventory(WF1): ID# System Name:Bill Yandle Conrad Person:Arleta ElselelArcadia Drilling Day Phone:380-426-3395 Cell Phone: - - Emai arietatiarcadiadrilling.com Eve.Phone: Send resin b:(PrInt Fut name,addrass and zip code or e-mar) arletatarcadiadriiling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample adleded by(name):Max Speaic location where sample collected: Spedal nsburdlans or comments Well Head 8BNX260 860 W Clear Lake Dr,Shelton Type of Sample(check only one box)- 1.0 Routine Distribution Sample 2.Repeat Sample(after onset.routine) Chlorinated Yes El No❑ 0 Distribution System Chlorine Residual:Total_Free lhnsaisfadory routine lab number. 3.Source Ground Water Rule Sample IS ! I Unsatisfactory routine coiled date: I 1 ❑Triggered Chlorinated:Yes❑ No El 0 AssessmentChlorine Residual:Total—Free_ 4. Enumeration Source Water Sample IS I I 0 E coil ®Fecal-sutaoo.GM,sFr gx Feared Yea❑ mop 5.0+ Sample Cdeeled for Information only. LAB USE ONLY DRINKING WATER RESULTS LAB ONLY ❑Unsatisfactory Total Coldorm Present and atisfactory ❑Ecolpresent ID Ewa absent Replacement Sample Required: 0 Sample too old(>30 hours) 0 TNTC ❑ _ Bacterial Density Results:Total Coliform- _ /100mL E.coU 1100m1: Fecal Cohlomr__— /100m1 HPC --- PI MI. Lab ID Number Date and Time Fteceiwed: SEP Li ?fin 1 A/\13 Method Code: Data andlime�Iracrbated: SM 9223 B f2CZ, Data Analyzed: d SEP 1 L 1022 Date Reported: SEP 22 Z022 DOH LabSaagiell 5 F,. lab Use om 22 0a1rer:ru1,319Kral.,0614.tlycvHeld rife+ mosnmr(RUTTY wrrrt Ira aidedirporestas am wet-4,d r r dcinteatlM}graMr.