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Home My WebLink AboutWAT2025-00081 - WAT Application - 3/31/2025 - 401:- ' ., WAT26 2.7 - 00c*i MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 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 this application. Part 1: Applicant/ Parcel Identification Name on Applicant: /4/e 1lei--- 13, /UVi c- Date: .3-3 1 — 2.025 Mailing Address: 3177t / I C j 5,�c4buvn,t/A-vc2/phone: (209 4/Sy— 2 42 90 Parcel Number: S-2 02/3 ! 9002 x Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 14 Building permit r'71 e i 2_t'--� - to-1�1 connections) 0 Division of land: 14 Individual water source (one connection), #of Parcels? SPL 'a Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) O 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: Wat acility Inventory(WFI) Number: (write"n "for two-party) O I am the manager of this s stem. The water syste een approved for services. There are presently con 'on(s)in us is will be the connection. ❑ I am the manager of this system. This c c I 'II be to upgrade or change the use of an existing connection on this system (i.e.: ational to full time . ase indicate on the following line the nature of this change: This waters Is able and willing to provide water to this (these)co ction(s)without exceeding the li ' 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. 1:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth it [ ft. `--� Well capacity Test(attached to application) V gpm ✓ L�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. \(9 Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 141 1 151 1161 1221 I Water use or limitation recorded N/A= Yes I-1 Well Drilled Date ,3/2,--4,s-- Individual Spring/Surface Water ❑ WDOE permit(attach to application) 0 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: \if 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. Cl 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: fir, I Environ. Health: p\/) Date 2c* 2of2 CSD Director: Date • WATER WELL REPORT _-__ DEPARTMENT OF Notice of Intent No. WE59146 ECOLOGY Unique Ecology Well ID Tag No. BRR 102 Type of Work: State of Washington J Construction Site Well Name(if more than one well): 0 Decommission t=> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: 1 l Domestic 0 Industrial 0 Municipal Property Owner Name Alex Burich 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 20 W Simpson Rd Construction Type: Method: New well 0 Alteration 0 Driven 0 Jetted C('able Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug I,Air- C Mud-Rotary fax Parcel No. 52001-34-90083 Dimensions: Diameter of boring 6 in.,to 120 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 119 ft. if yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I ❑ 6 in. +1 119 .25 in. O I ❑ 0 I ❑ Location(see instructions on page 2): C WWM or 0 EWM O 1 ❑ in. tn. ❑ 1 0 DID SW /-/ofthe NW %.;Section 01 Township 20N Range 05 O I 0 in. in. ❑ I 0 0 1 0 ❑ 1 ❑ in _ in ❑ 1 ❑ DID Latitude(Example:47.12345) 47.24396 Longitude(Example:-120.12345) -123.25584 Perforation!: I Yes I l No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations in.by in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑Yes ❑O No 0 K-Packer Depth ft- information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter in. Slot size_ in.from It.to ft. Top soil 0 1 Diameter in. Slot size_ in.from_ft.to ft. Sand,gravel,some silt,brown/soft 1 16 Sand,silt,brown/soft 16 66 Sand/Filter pack:0 Yes l No Size of pack material_in. Sand,gravel,silt,brown/hard,wb 66 75 Materials placed from ft.to_ft. Sand,gravel,more silt,some clay,brown/hard 75 95 Surface Seal: O Yes 0 No To what depth? 18 ft. Sand,gravel,silt,gray/hard,wb 95 106 Material used in seal Bentonite Granular Sand,gravel,silt,brown/hard,wb 106 120 Did any strata contain unusable water? ❑Yes O No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name N/A Type: H.P._ Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing +1 ft.above ground surface Static water level 44 ft.below top of well casing Date 3/25/2025 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? (No 0 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-- —4--• • ---- - top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test _ Bailer rest gpm with_ft.drawdown after hrs. Air test 50 gpm with stem set at 117 ft.for 1 hrs. - Date 3/25/2025 Artesian flow gpm - Temperature of water_°F Was a chemical analysis made? 0 Ycs ❑a No Start Date 3/25/2025 Completed Date 3/25/2025 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❑Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature C i _..,,.:1_ --3-1 a s.i t—. Address 1162 NW State Avenue City,State,Zip Chehalis,WA 98532 License No. 2253 Contractor's IF TRAINEE:Sponsor's License No. Registration No. MOERKSP072N5 Date 3/26/2025 Sponsor's Signature F.CY 050-1-20(Rev 11/18) Jf you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 7118o7 8Washington Relay Service. Persons with a speech disability can call Vanguard Laboratory ..VP 2635 Parkmont Lane SW . a; Olympia,WA 98502 360.967.7010 JANGUAR Report of Laboratory Analysis LABORATORY "' Collected by: Moerke and Sons • Matrix Drinking Water i 360-748-3805 Laboratory ID: V250408-26 Sampling Address: Date Sampled: 4/8/25 16:00 , / � 20 W Simpson Rd 3000 Sil ma-CI-1 h P-4J Date Received: 4/8/25 17:15 Shelton,WA 98584 Date Reported: 4/9/2025 Sample ID: 20 W Simpson Rd Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch 1D:V250408-26 Analyst:AF Coliform,Total Negative 1 1 MPN/I00 mL 1 4/8/25 17:44 E.coli Negative 1 1 MPN/100 mL 1 4/8/25 17:44 Nitrate by Hach Method 10206 Batch ID:V250408-26 Analyst:KS Nitrate(as N) 0.627 0.50 10.00 mg/L I 4/9/25 13:45 i • otes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/09/2025 n/a:not applicable SDRL:State Detection Reporting limit Approved by Tori Johnson,Operations Manager on 04/09/2025 • DF:Dilution Factor ilr._ 17025:2017 MCL:Maximum Contaminant Level ii i, AccRrtAI2 • Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing cCi vanguardlaboratory.com i www.vanguardlaboratory.com 1 of 1