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HomeMy WebLinkAboutWAT2025-00058 - WAT Application - 3/11/2025 • WAT a2d5 - 006 MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6h 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: lAerif1e(.-^ �i L Aitiacktik Ei 1'D Date: 03`,I (207,5 Mailing Address: 20 W ti(n2ti (- litAM.c. Or Phone: 310O- S3,3 - 2.1618 Parcel Number: 320Z(oi-I(RO (y; Type of Water System Reason for Application ❑ Public/Community Water System (2 or more -Building permit 5-O03 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL jii1/ Well ❑ Boundary line adjustment 0 Spring/surface water ❑ 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) ❑ 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:AEH Forms\Drinking Water Revised I2520I8 _._ Individual Water Well Water well report(attached to application). Depth l -}1 ft. Well capacity Test(attached to application) A'‘I }.e51-• )00 gpm '7 kdk 0 0 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://qis.co.mason.wa.us/planninq 141—I 151 116[1 221 Water use or limitation recorded N/A 0 Yes 1 i Well Drilled ... Date 0.4 f 2.6ZZ_ Individual Spring/Surface Water 0 WDOE permit(attach to application) El 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 4 • • 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: f 7 CCYV Environ. Health: Date L1 J�/ ,of CSD Director: Date -a WATER WELL REPORT ,1 ,41 DEPARTMEN1 OF Notice of Intent No. WE47607 ECOLOGY Unique Ecology Well ID Tag No. BNV865 Type of Work: 11.111p .State of Washington O Construction Site Well Name(if more than one well). 0 Decommission r > Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Amanda Elliott ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address xx Trillium Lane Construction Type: Method: O New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug ❑g Air- ❑Mud-Rotary Tax Parcel No. 32026-41-90143 Dimensions: Diameter of boring 6 in.,to 197 ft. Was a variance approved for this well? ❑Yes O No Depth of completed well 197 R_ Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I ❑ 6 in. 0 192 .025 in. DI I ❑ 0 I ❑ Location(see instructions on page 2): 13 WWM or❑EWM ❑ 1 ❑ in. in. O 1 ❑ 0 1 U NE 'h-'h of the SE 'h;Section 26 Township 20N Range 3W ❑ 1 0 in. _ in. ❑ 1 ❑ 0 I 0 O I ❑ in. _ _ in. O 1 0 ❑ I 0 Latitude(Example:47.12345) 47.192118 N Longitude(Example:-120.12345) -123.015309 W Perforations: ❑Yes Il No Type of perforator used No.of perforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Perforated front R.to R.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: ❑O Yes ❑No ©K-Packer ' Depth 191 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5" Slot size.012 in.from 192 R.to 197 R. Gravelly brown silt,dry 0 2 Diameter Slot size in.from R.to ft. Brown clay-like silt,dry 2 6 Brown fine to medium sandy gravel,silt bound, 6 Sand/Filter pack:❑Yes O No Size of pack material in. Materials placed from R.to R. tight,dry 22 Surface Seal: IJ Yes ❑No To what depth? 20 ft. Brown fine sand,dry 22 27 Material used in seal Bentonite Chips Brown gravelly silt,tight,dry 27 33 Did any strata contain unusable water? ❑Yes El No Brown fine silty sand,wet 33 43 Type of water? Depth of strata Gray silt,stiff,dry 43 56 Method of sealing strata off Brown fine sand,wet 56 63 Gray soft silt,moist 63 71 Pump: Manufacturer's Name Type: Black sharp occasional gravel,gray stiff clay,dry 71 99 t1.P. Pump intake depth:_ft. Designed flow rate: gpm Black gravelly silt,heaving 99 104 Water levels: Land-surface elevation above mean sea level 86 R. Gray clay,hard,dry 104 113 Stick-up of top of well casing 1 R.above ground surface Static water level 65 R.below top of well casing Date 7/29/22 Black gravelly fine to medium sand,silty, 113 Artesian pressure lbs.per square inch Date wet,tight 118 Artesian water is controlled by (cap,valve,etc.) Black medium sandy gravel,tight,wet 118 133 Black gravelly medium sand,heaving,silt 133 174 Well Tests: Was a pumping test performed? ©No ❑Yes r—) by whom? Black fine to medium heaving sand, 174 Yield gpm with ft.drawdown after hrs. Clean,water 197 Yield gpm with ft.drawdown alter hrs. Yield gpnt 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 Time Water Level Time Water Level Date of pumping test_ Bailer test gpm with R.drawdown after hrs. Air test 100 gpm with stem set at 140 R for 1 hrs. - Date 7/29/22 Artesian flow gpm _ Temperature of water 51 °F Was a chemical analysis made? ❑Yes KI No Start Date 7/29/22 __ Completed Date 7/29/22 _ 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. (]Driller❑Trainee❑PE—Print e P hian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 7/29/22 ECY 050-1-20(Rev 09/I8) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6871. Persons with hearing loss can call 711 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: Amanda Elliott Well Tag #: BNV865 Phone: (360) 338-2198 Depth: 197' Well Site Address: 93 SW Trillium Lane, Shelton Pump Set: 141' Date of Test: 10/3/2022 Static 66.5' TIME GPM LEVEL RECOVERY 1 Min 4.0 67.3 TIME LEVEL 2 Min 4.0 68.1 1 Min 67.8 3 Min 4.0 68.1 2 Min 67.0 4 Min 4.0 68.1 3 Min 66.5 5 Min 7.5 68.0 6 Min 7.5 69.0 7 Min 7.5 69.2 8 Min 7.5 69.3 9 Min 7.5 69.3 10 Min 9.5 69.3 15 Min 9.5 70.4 20 Min 17.0 70.5 25 Min 17.0 73.8 30 Min 21.5 73.8 35 Min 21.5 75.2 Vanguard Laboratory V 2635 Parkmont Lane SW, Suite A Olympia WA 98502 vexot7.agz 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 05/08/2025 = s 5 ❑AM lJ PM bbnth Day Yea Type of Water System(check only one box) ❑Group A ❑Group B 0 Other_.,_ Group A and Group B Systems—Provide from Water Facilities Inventory(WFI). ID# 1 System Name: Amanda Elliott Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results to:(Print full name,address and zip code or e-mail) arleta©arcadradnlling corn AND jenn@arcadiadrilleng.com SAMPLE INFORMATION Sample collected by(name).Max Specific location where sample collected: Special instructions or comments. BNV865-93 SE Trillium Ln,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2 ❑ Repeat Sample(NP) Chlorinated:Yes__ No (from disc buton system after unsat routine) Unsatisfactory routine lab number Chlorine Residual:Total Free.___ 3 Ground Water Rule Source Sample Unsatisfactory routine collect date. S 1 / I Chlorinated Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (AP) 4. Surface or GWI Raw Source Water Sample(Enumeration) S ❑E.col/ 0 Fecal F.'F*ed Yes N, 5.❑Q Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory ❑E colt present 0 E.coh absent Bacterial Density Results:Total Coliform _/100m1. E.coli_ /100m1. Fecal Coliform _/100m1. HPC /1 ml. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/Time eceived. Lab Reference Number • os1cft1a10 +tQ:co UQ.V1oSpq—\I*\ `t ti/ Receipt Temp C. Method Code: 1, .' SM9223B Date Reported to DOH Lab Use Only 05/12/25 DOH Lab-Sampte# 4 285-50914 bon Fpm R101.319(enet2re 06,17)•8 you need hs ptbdeen on n tlrnaore tenet.cell 800 525 0127(1DO/rTY me ill) TM art aM µdaaWa ere evatade et raw OM q yorleank grMr