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HomeMy WebLinkAboutWAT2025-00084 - WAT Application - 5/21/2025 WAT 2025-00084 MASON COUNTY 415N.6t'Street Shelton,WA 98584 Shelton:360-427-9670.Ext.400 Public Health & Human Services Bclfair.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: J(nvk Date: a�- 00dc Mailing Address: /°() 40}c 3c)yv , fil u_j J Phone: .3(40" 4% `o?INK Parcel Number: 3d03S- `7S``, )L/ Type of Water System Reason for Application 0 Public/Community Water System (2 or more Jk" Building permit connections) 0 Division of land: 14 Individual water source (one connection), #of Parcels? SPL Il Well 0 Boundary line adjustment 0 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) ❑ 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. 0 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.masoncountywa.gov J:\EH Form\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). EXI.STI � J9dividual Water Well El Water well report(attached to application). Depth 258 R L A>T►cr U 70 ►Ply n- - WL-c aoay- )D/b27 El Well capacity Test(attached to application) 13 cvm >40gpd. 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. 51 Satisfactory bacteriological test within last year(attach to application). 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) xl 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. -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: IR vriml°'(iLizt. 5/21/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.c1ov Page 2 of 2 L/ \ ' ,9C2S -coo8 ECEIVED WATER WELL REPORT OEPAft1MENt or Notice of Intent No WE58555 ECOLOGY Urnque Ecology Well IL)lag No. BQC038 Typed Work: state of Washington ;'{ 12 2025 Site Well Name(it more than one well): C'rostrm:hon D Decommission r'-o Original tostallahon M)t No Water Right PermitlCertificatcNo ' Ai. A4der Street Proposed Ilse. M Domestic C)Industrial 0 httaticipal Property Owner Name James Belleville --... - o tkwaterneg n Irrigation tl mesa Well f7 cnnm Well Street Address 140 SE Ashley Rd__ -__ _ ---- Construction Type: Method: City Shelton County Mason --. 0 Dew welln 0 O tan Li tag Ill Air- 0 Mud-Rotary Tax Parcel No. 32035-75-90041 Deepening 0 Other Dimensions: Diameter ofbonng 6 in.to 280 ft. Was a variance approved for this well? 0 Yes d' No Depth ofeompkted well 258 O. If yes.%Aid Kos the van ntnce t rl Construction Details: Wall Casing Liner ter From To thickness Steal PVC Welded 7lraad [j WWM Or©EWIvt © 1 0 e in. 0 253 .25 in. Cy I 0 l 1 0 location(se nttilnnuons on pane 2) O 1 0 in. _ ._ _M. O I 0 0 I O NW YrY.of the NE '/.;Section 2 Iownship 19N Range 3W ❑ 1 ❑ ia. ,in O I O O I t7 Latitude(Example:47.12345).47.16868 N D I ❑ --ia -- —i'" 0 1 Cl 0 I n Longitude(Example:-120.12345) -123.02055 W --- Perforations: 0 Yet II No Type o<peribru°f used Drilier's Leg/Coastr^uetioe sr DeeommissiOa Procedare No of perforations_ Sim ofperfataiiom—in.by--in Formation:Describe by color,dwacter.six of naaerOI and structure,and the kind and Perforated from R to R.below graved surface nature of the material in each Myer penetrated,with at least one entry for cacti chaotic of Ili K-Packer c� Depth 25252 ft. information. Use additional sheds if accessary. screen: ran Yes U No Material Fran To Manufacturer's Name,Alloy Machine Works_ 14 Type wire-wral�d Maid No. Brownish gray sandy fine gravel,siithound,till t 0 Diameter 51 Stet sirs.014 in from 253 ft to 258 A 14 ft to_ft Brownish gray silty fine sand and proven,day � Ihontder Slot size!_in from _,-- J_ binder ----- Semi/Filter park:U Yes IR No Sire of pack material*in Grayish brown fine sandy gravely , 23 33 day,wet,soft Materials placed from ft.to`tt. Gray fine to medium silty sandy gravel,loose,wet 33 45 Surface Seal: 10 Yes 13 No To what depth' 19 n Brownish gray fine sandy silt.soft,wet 45 59 Material used in seal Bentonite chips Bluish gray silty day,hard,sticky 59 66 Did any strata coraain unusable water? ❑Yes bl No Bluish gray silty clay,some gravel,soft,wet _ .._.w_ 83 Type of wale Depth pratfall Gray fine sandy silt,fine to medium gravel,weeps 83 108 Method of sealing strata oft' Brown fine to coarse gravelly silty sand,weeps 108 120 Pump: Slanufae— turer's Name Type. Brown fine to coarse sand,fine CO medium multi- 120 N.P.___. Pump Intake depth: ft. Designed lbw rose____Wo cola ed gravel,tight,weeps 130 Brown fine to coarse sand,multi-colored fine to 130 !!'stet Lerch: Land-surface ekvauwe above mean tea lcsd 145 ft '----- .__ 138 Stick-up oftop dwell casing 1.5__ft above ground smrfax medium gravel,loose,weeps Stacie water level 130 R.Wow top of well casing Dale 1/20125 _ Gray fine silty gravelly sand,moist,tight 138 145 Artesian pressure Ibs per square arch Date Gray silty fine sand and gravel,wet 145_- 173 Artesian water is controlled by reap.valve,eta:.) — _ 173 180 44 Gray fine sandy day,weeps,stiff Well Tests: Gray sticky day,stiff 10 hard 180 210 Was a pumping test performed? PJ No O Yes t by whom?-.__...._..___.-_.____..... Greenish gray day.hard 210 221 Yield spin with R drawdown after_,__ran Gray fine to coarse sand.fine multi-colored 221 Yield _—spin with R.draw down aver his 229 Yield gpm with_ft diawdown after lets gravel.weeps,heaving Recovery data(time=nem when pump es turned off--water level measured horn well Gray fine to coarse silty sand,weeps.tannins 229 252 top to water level) Gray fine to coarse sand,fine to medium multi- 252 time Water Level Time Water Level Time Water t.cscl colored gravel,heaving,water bearing 259 — Brown fine to coarse silty sand_wnod chips.moist 259 260 Date of pumping tea_._____ ...... . Railer Railer test rpm with,r 11 diewdown after__ has.. Air test 60 spin with seem let at 240 fi lest 1 Ius • Date 1/20/25 Artesian foss Wna 1 Temperature of water 51 "F Was a chemical analysis made? O Yes E)No Start Date 1/16/25 Completed Date 1120/25 WELL CONSTRUCTION CERTIFICATION: I constructed andior accept responsibility for construction of this well,and its compliance with all Washington well • ecsnstnad+on standards.Materials used and the information reputed above arc tru to my best knowledge and beltcf. 0 Driller<3 Trainee 0 PE-Print Nam ry Johnson trilling Company Arcadia Drilling Inc. Signature Address Address PO Box 1790 _ • License No.3441T‘r tJ City',State,Zip..Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2053 Contrachw's Sponsor's Sigrlattue _...-._ Registration No ARCAD01098K1 Date 1/20125 f.CY 050-1.20(Rev 09/18) Ijvota need this efocuna'al in an alternate format.please call the Water Resoarces Program at 360-407-6872. Persons with hearing lass can ca!!711 for Washington Relay Service. Persons with a speech disability can call877-833-6341. ct- 9bc9 - F RECEIVED Arcadia Drilling Inc. P.O. Box 1790 MAY 12 2025 Shelton,WA.98584 Customer: Jim Belleville Well Tag#: BQC038 i%:.15 W. Alder Street Site Address: 140 SE Ashley Rd, Shelton Depth: 258' Date of Test: 2111125 Static: 122' Pump Set: 240' TIME GPM LEVEL RECOVERY 1 Min 6.3 123 TIME ] LEVEL 2 Min 6.3 123.2 1 Min I 122 3 Min 6.3 123.3 4 Min 6.3 123.3 5 Min 8.5 123.3 6 Min 8.5 123.5 7 Min 8.5 123.6 8 Min 8.5 123.8 9 Min 8.5 123.8 10 Min 13 123.8 15 Min 13 124.9 20 Min 13 124.9 25 Min 13 124.9 30 Min 13 124.9 35 Min 13 124.9 40 Min 13 124.9 45 Min 13 124.9 50 Min 13 125 55 Min 13 125 1 Hr 13 125 1 Hr 10 Min 13 125 I I I I y I I 1 -- --- 1 Vanguard Laboratory 1 2635 Parkmont Lane SW,Suite A Olympia WA 98502 v! T84�D 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM R E C E I V E D Date Sample Collected ! Time Sample County Collected 02/21/2025 1 2 . Mason I MAY 12 2025 PIA WO Or" Yea i Type of Water System(check 1l�one box) 15 W. Alder Street 0 Group A 0 Group B 111.0111.1 Group A and Group B Systems-Provide from misreading I gsany(eel) Wit _ _ _____ ____._.. SYstem Narne Jim Belleville Contact Raman Arcadia Drilling.Inc 1 Day Phone(360 )426-3395 Cell Phone( ) Email: Eve.Phase:( ) Seed wallets(Peseta name.address and zp code or a rrtal) SAMPLE INFORMATION sample cued by(norm°Shad Spec%c location vmere sample colecled Special mstrucliors or comments BQC038-140 SE Ashley Rd.Shelton Counts please Type of Sample(select only one type of sample from types I ttsough 5 below) 1 ❑Routine Distribution Sample(AIP) 2.0 Repeat Sample(AlP) Chlonnated Yes No (awn d tetuton system alter ursat routne) Unsatisfactory routine tab number Chlorine Residual Total__,Free 3 Ground Water Rule Source Sample Unsatisfactory routine collect date Chlorinated:Yes No ❑Triggered(A1P; Chorine Residual.Total Free i D Assessment (AvP) 4. Surface or GWI Raw Source Water Sample(Entmterabort) $ i 1 I ❑E cot 0 Fecal Rand Ya. _No 5 ®Samye cceeceo r tnfamatim Only. tAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY - ❑Unsatisfactory Total Colifonn Present and f X Satisfactory D E col,pre ent D E;.rot absent I Bacterial Density Results TotalColiform <1.0..-.l1O0n1 E.cc <1.0 r1c0.T iFeca'Coifcvns /100mi HPC _ /1 mi. riptacement Sample Required: 0 TNTC 0 Sample too rid I 1 0 Sample Vciurne 0 Damaged Conte ner 0 11__- • Dakar*Received La Resew*Number i Q_2(_11 Y 2". 0-n--1 — 1 L _..._ temp "ee'°d"°de SM9223B 1 Dale Reported to DOH tab Use Only • 1 0044 taS-Sar les .. 285- 22116 50ers411-tt m,45r7.r,a...d Mmia.b.•wrr•rwtmit a/see saws morn al hi) fha ed*a gYefOea and waft*a ova sn a pA`igarl