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Home My WebLink AboutWAT2025-00077 - WAT Application - 4/17/2025 WAT 2025-00077 i( % MASON COUNTY..______ •1 COMMUNITY SERVICES „ v (;wilding,Planning,Environmental Health,Community Health 0 415 N 6th 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: JEAN BOELK Date: 4/17/2025 Mailing Address: 7603 98th Ave SW Lakewood WA 98498 Phone: Parcel Number: 319303100010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit connections) ❑ Division of land: % Individual water source (one connection), #of Parcels? SPL X Well ❑ Boundary line adjustment 0 Spring/surface water 0 Other(explain) 0 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:1EH Forms\Drinking Water Revised 1/25/201 R Individual Water Well X Water well report(attached to application). Depth 187 ft. ® Well capacity Test (attached to application) 26 gpm >400 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/planning 14_15_16_22_ Water use or limitation recorded N/A Yes Well Drilled . . . Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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) XI 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: -)Ateriv i(At 4- 6/6/25 Environ. Health: Date CSD Director: Date 2 of 2 WATER WELL REPORT 0,.',:;; ,`:. DEPARTMENT OF Notice of intent No. WE57933 ECOLOGY Unique Ecology Well ID Tag No. BQL 631 Type of Wnrh: State of Washington Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: L•J Domestic 0 Industrial C Municipal Property Owner Name Nick Boelk ❑Dewate(ing 0 Irrigation ❑Test Well 0 Other — Well Street Address 1141 W Hurley Waldrop Rd Construction Type: Method: L9 New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug ❑O Air- ❑Mud-Rotary Tax Parcel No. 319303100010 — Dimemlom: Diameter of boring 6 in.,to 280 ft, r Depth of completed well 187 ft Was a variance approved.or this well? ❑Yes E No Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread ❑r I 0 6 in. +1_5 187 .25 in. Ii7 I ❑ DID Location(see instructions on page 2): l l WWM or L I EWM ❑ 1 0 in. in. 0 I 0 ❑ I 0 SE ''/4-1/4 of the NE ''A;Section 30 Township 19N Range 03 ❑ I ❑ in. _ in. ❑ I ❑ 0 I 0 ❑ I ❑ in. _ _in. ❑ I ❑ U I ❑ Latitude(Example:47.12345) 47.10591 Longitude(Example:-120.12345)_ 123.10976 ___.._ Perforations: 0 Yes C[No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to ft.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 ono entry for each change of Screens: LI Yes !a1 No 0 K-Packer r Depth ft. information. Use additional sheets if accessary. Manufacturer's Namo Material From To Type Model No. Diameter in. Slot size— in.from fi.to ft. Top soli 0 1 Diameter in. Slot size— in.from—ft.to ft. Sand,silt,some gravel,brown/hard 1 6 Sand/Filter pack:C1 Yes !1 No Size of pack material in. Slit,clay,sand,cemented,graylhard 6 25 Materials placed from ft.to ft. Clay,slit,sand,some gravel,gray/soft 25 34 Surface Seal: 0 Yes 0 No To what depth? 18 tt Clay,gray/hard 34 95 Materiel used in seal Bentonite Granular _Sand,pea gravel,slit,gray/soft 95 105 Did any strata contain unusable water? 0 Yes O No Clay,gray/soft 105 153 Type of water? Depth of strata Clay,blue-gray/herd 153 164 Method of sealing strata off Clay,little sandy,blue-gray/soft 164 174 Sand,silt,water,fine sand,vary silty,blue/soft 174 184 Pump; Manufacturer's Name NIA 'Gyps: Sand,some gravel,brown/soft,wb 184 186.5 • H.Y.— Pump intake depth:_ft. Designed flow rate;—gpm Clay,gray/hard 186.5 194 Water Levels; Land-surface elevation above mean sea level ft. Clay,some sand,some gravel,pray/soft 194 199 Stick-up of top of well casing_+1.5 ft.above ground surface Statio water level, 103 ft.below top of well casing Date 1 0/2 1120 2 3 Sand,sill,some clay,brown/soft 199 213 Artesian pressure lbs.per square inch Date Clay,some gravel,gray/hard 213 219 Artesian water is controlled by (cap,valve.etc.) Clay,some gravel,gray/hard 1 219 230 Clay,gray/hard 230 280 Well Tests: Was a pumping test performed? IN No 0 Yes c1> by whom? Yield gpm with ft.drawdown after hrs. Yield yen with_ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time-zero when pump is tamed off-water level measured from well top to water levee)Time Water Level Time Water Level Time Water Level — Date of pumping test - Bailer test gpea with 8.drawdown after_hrs. - Air test 26 gpm with stem sot at 185 ft.for 1 his. - Date 10/21/2024 Artesian flow gpm - Temperature of ware( °F Was a chemical analysis made? 0 Yes CM No Start Date 10/18/2024 Completed Date 10/21/2024 WELL CONSTRUCTION CERTIFICATION: I constntcted 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. E Driller 0 Trainee 0 PF,-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature C. ��. ;: 'I-nn,/ti., Address 1162 NW State Avenue License No. 2253 City,State,Zip Chehalis,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072N5 Date 10/22/2024 - ECY 050-1-20(Rev 11/18) Ifyou need this document in an alternate 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. JiCt VDCD.ei Vanguard Laboratory 2635 Parkmont Lane SW t. .to' Olympia,WA 98502 360.967.7010 VANGUA1E ,pr Report of Laboratory Analysis LABORATORY Collected by: Moerke and Sons Matrix Drinking Water 360-748-3805 Laboratory ID: V250603-I8 Sampling Address: Date Sampled: 6/3/25 15:00 1161 W Hurley Waldrip Rd Dale Received:6/3/25 16:53 Shelton,WA 98589 Date Reported:6/4/2025 Sample ID: 1161 W Hurley Waldrip Rd Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&C.toll by SM 9223B(1D1;XX) Batch ID:V250603-18 Analyst:AF Coliform,Total Negative 1 1 MPN/100 mL 1 6/3/25 17:24 F.colt Negative 1 I MPN/100 mL 1 6/3/25 17:24 Nitrate by Hach Method 10206 Batch ID:V250603-18 Analyst:AF Nitrate(as N) ND 0.50 10.00 nig/L 1 6/4/25 9:00 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 06/04/2025 rda:not applicable SDRL:Stale Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 06/04/2025 DF:Dilution Factor 1.1 ` 1702Srt017 MCL:Maximum Contaminant Level 1.; Loma oa.V 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 testingta'3vanguardlaboratory.com www.vanguardlaboratory.com 1oft