Loading...
HomeMy WebLinkAboutWAT2025-00052 - WAT Application - 4/29/2025 WAT 2 oa6 - 0e1)5?- _„,n.; . MASON COUNTY COMMUNITY DEVELOPMENT RECEIVED Permit Assistance Center,Building,Planning MAR 1 1 2025 415 N 69n Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •: Elma: (360)482-5269 eS 4 W_ Alder Street 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 this application. Part 1: Applicant! Parcel Identificationti ��� Name on Applicant: W\�\�,- �,((5A Date: ! \DIp Mailing Address: • \` CONICS �11 `1 c one: '°R D" 1 M g � 1 `� �C1 �J Parcel Number: P2,0,D"k-a' - 000.'0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit BLb AS r OO .-` 7 connections) 0 Division of land: tit Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ 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 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) O 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. 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 ----(0 O ft. ❑ Well capacity Test(attached to application)_ gpm �oU 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. Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14E 15n 16r-1 22= Water use or limitation recorded N/A 0 Yes J—] Well Drilled 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) r 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. I-1 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: Environ. Health: 1') � {'V-� � b\(\n Date 1-11 kc CSD Director: Date 2°' , WATER WELL REPORT o.., 0 DEPARTMENT OF Notice of Intent No. WE35505 ECOLOGY Unique Ecology Well ID Tag No. BAR940 Type of Work: State of Washington 0 Construction Site Well Name(if more than one well): 0 Decommission i=> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ©Domestic 0 Industrial 0 Municipal Property Owner Name Daryl VanHoff 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 681 Highland Hills Road Construction Type: Method: CityShelton County Mason 8 New well ID Alteration ❑Driven 0 Jetted 0 Cable Tool 0 Deepening O Other ❑Dug 0 Air- 0 Mud-Rotary Tax Parcel No. 520261100000 i . Dimensions: Diameter of boring 6 in,to 260 ft. Was a variance approved for this well? ❑Yes 12 No Depth of completed well 260 ft. -- If yes,what was the variance for? Construction Details: Wall . Casing Liner Diameter From To Thickness Steel PVC Welded Thread ® I 0 6 in. 0 59 .250 in. IR I 0 Cal I 0 Location(see instructions on page 2): C3 WWM or 0 EWM ❑ I ® 4.5 in. 20 ?ea _in. ❑ I 0 ❑ I ❑ NE %.-1/4 of the NE ''A;Section 26 Township 20N Range 5W ❑ I ❑ in. in. ❑ 1 CJ L I 1 ❑❑ 1 El in. in. ❑ I ❑ Cl 1 ❑ Latitude(Example:47.12345) 47.199688 _ — � _ Longitude(Example:-120.12345) -123.267759 • Perforations: Oa Yes 0 No Type ofperforator used Pre-Slotted Liner Driller's Log/Cotutructloaerr Decommission Procedure No.of perforations Size of perforntions .032 in.by in. Formation:Describe by color,character.size of material and structure,and the kind and Perforated from 140 fL to 260 ft.below ground surface nature olihe material in each layer penetrated,with at least one entry for each change of •• Screens: ❑Yes LJ No ❑K-Packer r) Depth_ft. information. Use additional sheets if necessary. Manutimhunr's Name • Material ,•,'• From" `To' -7., - • is Model No. Brown silty sand&gravel,loose 0 3 Diameter_ Slot size_in.from ft.to_fl. Diameter Slot size,in.from _ft.to_ ft. Brown silty sand&gravel,tight 3 10 Brown claybound sand&gravel 10 14 Saad/Filterpnck ID Yes l l No Size of pack material in. Sharp multicolored gravel with brown silt binder 14 22 Materials placed from_ft.to II. Gray clay hard 22 30 Surface Seal: RI Yes ❑No To urluat depth? 19 ft. Brown silty clay 30 48 Material used in seal Bentonite Chips Gray shale 48 109 Did any strata contain unusable water? 0 Yes IC No Type ofwater? Depth of strata _ Black basalt 109 120 Method of sealing strata off Black basalt fractured 120 121 Black basalt 121 160 Pump: Manufacturer's Name Type: Black basalt,fractured,water 160 170 H.P. Pump intake depth:�ft. Designed flow rate:_gpm Black basalt moderate 170 221 Water Levels: Land-surface elevation above mean sea level 580 ft. Black basalt hard 221 260 Stick-up of top of well casing 1 IL above ground surface Static water level 189 ft.below top of well casing Dote 8/13119 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test perfonned? RI No 0 Yes => by whom? ' Yield gptnwith ft.drawdownofter..................lies, Yield gpm with_ft.dmwdown after_Ire. Yield gpm with ft,drnwdown after Ire. 4 Recovery data(time—zero when pump is turned off—water level measured from well l top to water level) Tune Water level Time Water Level Time Water Level Delo of pumping test Bailer test gpmwith ft.drawdown after_hrs. } Air test 2 gpm with stem set at 259 ft.for 1 less. Date 8/13/19 Artesian flow gpm j Temperature of water 50 °F Was a chemical analysis made? 0 Yes FJ No Start Date 8/12/19 Completed Dale 8/13/19 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 arc true to my best knowledge and belief. O Driller 0 Trainee CI PE-Print N os ua Koepp Drilling Company Arcadia Drilling Inc. Signature /' Address PO Box 1790 License No.2874 City,State,Zip Shelton,WA 98584 111 IF TRAINEE:Sponsor's Liken o. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 8/14/19 ECY 050-1-20(Rev 09/18) If you need this document In an alternate formal,please call the;Parer Resources Program at 360-407-6872. Persons with hearing loss can call 7/l for Washington Relay Service. Persons with a speech disability can call 877-833.6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Daryl VanHoff Well Tag #: BAR940 Phone: 253-310-7215 Depth: 260' Well Site Address: 681 Highland Hills Rd, Shelton Pump Set: 250' Date of Test: 9/24/19 Static: 45.7' TIME GPM LEVEL RECOVERY 1 Min 8.5 5.8 TIME LEVEL 2 Min 8.5 60 1 Min 217.4 3 Min 8.5 66 2 Min 215.3 4 Min 8.5 72.5 3 Min 213.3 5 Min 8.5 80 4 Min 211.4 6 Min 8.5 88 5 Min 209.4 7 Min 8.5 96.8 6 Min 207.5 8 Min 8.5 100 7 Min 205.5 9 Min 8.5 104 8 Min 203.5 10 Min 8.5 108 9 Min 201.5 15 Min 8.5 133.5 10 Min 199.8 20 Min 8.5 156.5 25 Min 8.5 177.5 Z lZ 30 Min 3 195.9 35 Min 3 201.4 40 Min 3 207.5 45 Min 3 211.9 50 Min 3 215.9 55 Min 3 219.9 1 Hr 3 223.1 _ ct 0 1 Hr 10 Min 2 228 1 Hr 20 Min 2 226.1 1 Hr 30 Min 2 225 1 Hr 40 Min 2 223 1 Hr 50 Min 2 221.2 2 Hr 2 220.2 2 Hr 10 Min 2 219 _ (,p . .. • , • r,',$, 7. .•-..,,..ir-—..,Ftfpi. -,-,..,:.;!?v,. ..7.513..:.. " ..z,e.."•' •...... • - Thurston.CountVigilkiitonnlentrilfialth 1 . '4,,`• :''':'' •' .• '!":44,:.., "raiz Lillvlad:VE 4:Cityrnpla,WA 118506 , • ,, -.c- '1., • 360.467.-2611 , r...., i-4A. • • r H.M.4rt):4 C() Iv 0,..• ,...., •-,.. I .. . , ,... .....•.. . ',7--. -.r.-7: gurokticaoTERKANAtysis.: ...:,,,;,:,.... . ''''-'' '....-. • '`:-Top" my - •.. . ..--- , - Deosopows. : line s.illiVk ;WOW; .. ‘„,. , ... - ... • • . :',:i:::...;.,,•4.-;i ..6.,,..,/11 1.90. i'i...1:), -1.-;°.: 62:0,A,4: -MUthWiN ...;1''' • ''::'[.. : 1' view. nry um. .: ' , ''`' ''';•.,. '"‘P1.4 .. ': * .,•. ''7:• . iyieetvieter System(ollealsillif 0116104,,,, t_PrivElie 110.130011 ‘., .'',;,::;'.•:' 00E04 f.• ....fitrolip 1:4:-' *bather ..'7 • peep Aericl Gioagiti.141tlerrts-..Provkla from Water Fel:irides Inventory(WR); 1 • ' - lag...044-.. --aolbth..,...#0.1 ••!--- Aro-ww, 00-4.±. ,: • .• •, '''• 1 •,'. ▪ '•Systerdiareez : : . . .. . ,. ., oft ..:cik No. ' tkiiia .. ,__• :•-• • -', ▪ tyaiiihioitstiti...qt. ./...tel.v-t. • •:pophone:( ) ... : tinak, • ,*ta:.a.-...;.;.. f.t.1 i':, - .--P11— ' •); .: •• , • , - ;r',,4.7:4:4;.•i'ii•,:te.ti 1,,yrr.m.-..,•:..: .rwsKielFri'cowyoritio'. y.,,.s) ..,.....,....-;)-• • .........;' .•;.,.- . •, . ... — '. .... ..'' :.". . -A43,11461)5764."..1;1144,- - ' -- •' .-41''' -' ''''': -......- - •. '- '''''''' --- -..4.4100i... itiV•ptitilAtIO4 -1'7.* ,... , , , . V',Allirefie'';I''.'PY''';'''' '',.,..'-';''''U..,, .., '. ,,,, k-4$ .ic .. :,.„ ..4.4 , • , , n...:,„,:. 1 1...,,„ '„...,.- ..., vil,-...__.',..,,,F . — . • . •.' ,. . .... . ,...._ .. .„.,..' . -4-.."' • .• .';$0:41001604Kistfaitii vifieif tpie coteded SpecaI't•- •:.‘.. t3i....etiointioit'•• ...1kftk0:1 ' .RI WS.V4' '' • ...., ... .... .. ..:*iiiSatnpte(rnustofteckonly.eniboxerAtt Utrotlfiiliatedbew) .r : t, ;;.G1'..1(4011e9;Oletribe:tten.Saintifli ,'..'..f.ZIReeeeCikeetple.(aBe?ims41.401464 0 Dittrifititlan System • . • . •. .thicikit:***10.4.t.„,. .,.P*,.e. Pigorlfia($1.;*ts. ,,,,,;ficf -0. :iiawliaiiiS0(14:reinPkt-'..5: ' 'Chlorinti...iittsil.A0 iiee_,.-. --, ' 0 1. 13iNft( p), , . EiNogebiiii406****.i54 ,:fir*.etiti*titewrotittn0).0s numbii : Arlareeiee, . ND • . .. ,,,,,-,,,0•0...t....4r4 '.. .••••••••••........,..;174." '',' 0 Ailiginent-t 406,1119.(441P) '':. tinWtriti‘itbUtir4:.0142tt det*';': • ' - .;:. db0 .11,... ' .; - .„,, • .. : kJ ., ._ '' •• - ,.:/yr,- 1.„,,.., • .:. .. .. . •• ,.•-•!,....,,teksiirifoo...coliected forlrifOrrnatton Only:... ' ' . '''. , ( Investigative Congretlion i Repake_)(•___ '00ter.,••• - . . ;. •; 4.AfluE,oNy;-...;ORINKING•WATERREptlitte)FillAii—ii*VNIY • •, \ 0 UnsaUsfactori Total ColitonnPresi3nt add a Us,factory •• I s. N ,oll' 1 :,.1.•• 04(X0prasen .- . .tiScataberlet T'';:••;,,- • . o 1, . __... . .. ; :;',4r•..•"-•• •.,.' ..,•t: ! - ..*:-.' ', • '', .;itiptaetinikft SertipteArquIred: — -••.. 0.44.01010010g( ..ta T 0301kure/.. titC.,. -.. 0.rfit.. .",3„.... .....,.?...; ..'.....•::;,"...' ' 1 : : ,,... . ..,...... . • ..„..,.:_. ;,, .4 -k- 44i ,1,:. - :::Ltkr • ....41,e, I . i . Bacterial Density Resultsn Total Coliferra • • 1)00n4._ Etat • Iloomi . /low -...!.." :ecixtr, ' flop ni, .._• : . . - . iod COde:121.5k19223B 'CIBM 02210 ::.Pate and Time RecatyoltIVr,.: -..,. :•,..,,:„...,,,...;.. 0 tM B2158 'OrEiiterotertrb 'ii.,',.,y,......vitk: I , 00'.and1taxiAnaiyzot. '!5- 1 t5 .25 .,.1. ;;.g.::',.....00600oail'r:::; .z444.! &Trip**.(DOH flirter plis in*dailita) . .: .. -,..A.,02.:, '.1.11b .c:Pelf,,,•:::'.,, ',.,4"..." ,7,••'''' F'll...t ' :.::,••,K6W-:..:;?:tr"' 0 ' •• •-1 i t'•,.,f • r '..''.: ' i',",',;',"i7,0741,;'-4V,»?,'''4•`4.'"'r..4';',':;•..VM.;',,-..•'''.'.°..1':;:t.1 .••,w-,- • .•' r,-. . . -•., t• -t-.''..to 1 •, . ,• '•':',•:,b',:"' "I ., -,;••:':.i.1.-.,.:4•-' -',>:•,",..:•i.f.-..::,..-%;', ', . .D0H.Ilins3314-ts ornmpa..,ltig ., .,, ... ,.•,,.., 7,11 424.:',..,.',1flar, --7-7-,...':..:' ''' ;;,,•,..;!.:,3,,t4.5„--;ii.'?,&,''.,-..,.,,'.:•-• -:',:.:;;:;;;:ki ,,.''. -..y..:4, 4,:-..-;.:..,',.,:: , .::',',.,','...., ,,?..,..`•ti;* ",-,4;,ika,- ' ",.::-'',..;:c;-;',:;.'.:--:,,',..-..4.'-. - - ';...' ;,:vt-- '•-- A'.., :. . '.'''/.7.1'4,7'1,-'...,",