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Home My WebLink AboutWAT2025-00101 - WAT Application - 6/2/2025 i y O ) O11WAT MASON COUNTY 415N.6a'Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 ' Public Health & Human Services Belfair: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: 7�° ate: / MailingAddress: 4/0 t'C e r t4!!e hone: 3(QD—8 78- L 1/56 YV � y-�^l- p^� Parcel Number: ( 3017 7�J CO d 1 V Type of Water System Reason for Application 0 Public/Community �('y�� Water System(2 or more . Building permit gwaaa5 r�"� (0? connections) 0 Division of land: Individual water source(one connection), #of Parcels? SPL Well 0 Boundary line adjustment ❑ 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 Wafer 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) ❑ 1 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. 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 Forms\Drinking Water Revised 05/08/2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth 51 ® Well capacity Test(attached to application) 12 qpm >400 qpd. 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. LEI Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) O 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 0 Relationship to Applicant • • Part 3: Mason County Community Services Evaluation (staff use only). ® Satisfactorybetermination Thls determination does"not address`adequacy of the distribution system,guarantee an adequate supply:of i;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. -• . o" Unsatisfactory Determination: Applicant's"water'suppy does not appear adequate to meet the needs ofits' for the following .Jnte.�d4d� reason(s). •` ,',`' :,. y^ — Reyteta Signatures: • ,': • a r , Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of mow WATER WELL REPORT �:. !DEPARTMENT OF ECOLOGY Notice of Intent No. WE58496 Unique Ecology Well ID Tag No. BQC048 Type of Work: US State of Washington Site Well Name(if more than one well): ❑e Construction ❑ Decommission i=t, Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Mike Bever 0 l)ewateriag ❑Irrigation 0 Test Well 0 Other Well Street Address 130 W Doggone Ln Coast:medal Type: Method: CityElma County Mason ?<]New well ❑Altercation 0 Driven ❑Jetted 0 Cable Tool 0 Deepening 0 Other 0 Dug ®Air- ❑Mud-Ronny Tax Parcel No. 6201 T-75 00010 Dimensions: Diameter of boring 6 in..to 54 R Was a variance approved for this well? 0 Yes O No Depth of completed well 51 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread RIO 6 in. o 51 .25 in. 13 I 0 17 I 0 Location(see instructions on page 2): G WWM or❑EWM ❑ I 0 _in. _ _ in. ❑ I ❑ ❑ I ❑ NE '''h-Y of the NW ''A;Section 17 Township 20N Range 8W ❑ I ❑ __is — _ .__in. ❑ I ❑ ❑ I ❑ ❑ I 0 —in v ❑ I ❑ ❑ ❑ Latitude(Example:47.12345) 47.22751 N Longitude(Example--120.12345) -123.46770 W Perforations: El Yes 0 No Type of perforator used Star Driller's Log/Construction or Decommission Procedure No.of perforations 128 Size of perforations 1.25 in.by 3/8 is Formation Describe by color,character,size of material and structure,and the kind and Perforated from 19 ft to 23 ft below ground surface nature of the material in each layer penetrated,with at least one entry fix each change of Screens: 0 Yes El Nc 0 K-Packer b Depth ft information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Brown gravelly Clay loam,top soil 0 5 Diameter_ Slot size M.from ,ft to it Diameter_ Slot sae in.from ft to R Fine to medium multi-colored sandy gravel, 5 loose,wet 19 SaadlFilter pack:Cl Yes ®No Size of peck material_is Fine to medium multi-colored sandy gravel,loose 19 Materials placed from ft.to R Water beating 22 Surface Seal: le)Yes ❑No To what depth? is ft Reddish brown gravelly silt,wet 22 42 Material used in seal Bentonite chips Reddish brown gravelly clay,hard 42 45 Did any strata contain unusable water? 0 Yes D No Gray shale,hard 45 51 Type of water? Depth of strata Method of sealing strata off Pump: Manufeorurer'sName Type: H.P. Pump intake depth: R Designed flow rate:_gpm Water Levels: Land-surface elevation above mean sea level 410 ft _ Stick-up of top of well casing 1_5 ft above ground surface Static water level 2 ft.below top of well casing Date 3/21/25 Artesian pressure lbs.per square inch Date Artesian water is cocooned by (cap,valve,etc.) __ Well Tests: 1 Was a pumping test performed? El No 0 Yes r=l> by whom? i Yield_gpm with ft drawdown after_bra. ----- Yield_gpm with ft drawdown after bra Yield gpm with ft drawdown alter_hrs. Recovery data(time=zero when pump a turned off-water level measured from well top to water level) 4 Time Water Level Time Water Level Time Water Level — — Date of pumping test ^t Bailer test_gpm with ft.drawdown after l es. Air test 5 gyro with stem set at 25 it for 1—bus. Date 3/21/25 Artesian flow gpm 1 Temperature of water 51 •F Was a chemical analysis made? 0 Yes fl No Start Date 3/21/25 Completed Date 3/21/25 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with ail Washington well construction standards Materials used and the information reported above are true to my best knowledge and belief. 0 Driller O Trainee C PE—Print Name Cory Johnson Drilling Company Arcadia Drilling Inc. Signature i fi Address PO Box 1790 License No.3441 T . City,Stater Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2053 Contractor's Sponsor's Signature ` -, _— Registration No.ARCADDI088K1 Date 3/21/25 ECY 050.I.20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872 Persons with hearing loss can call711 for Washington Relay Service. Persons with a speech disability can ca11877-833.6341. 4 Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Mike Beyer Well Tag#: BQC048 Site Address: 130 W Doggone Ln, Elma Depth: 51' Date of Test: 3/28/25 Static: 2.6' Pump Set: 40' TIME GPM LEVEL RECOVERY 1 Min 6 3.1 TIME LEVEL 2 Min 6 3.1 1 Min 2.6 3Min 6 3.1 4 Min 6 3.1 5 Min 10 3.1 6 Min 10 3.5 7 Min 10 3.6 8 Min 10 3.6 9 Min 10 3.6 10 Min 12 3.6 15 Min 12 4 20 Min 12 4.2 25 Min 12 4.2 30 Min 12 4.2 35 Min 12 4.2 40 Min 12 4.2 45 Min 12 4.2 50 Min 12 4.2 55 Min 12 4.2 1 Hr 12 4.2 1 Hr 10 Min 12 4.2 (Total Gallons Pumped: 794 4 111 I I I I __TV Vanguard Laboratory I 2635 Parkmont Lane SW,Suite A Olympia WA 98502 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 04/02/2025 . _ ___ a PM Atrpi Day ''ear Type of Water System(check only one box) ❑Group A ❑Group B it Other Group A and Group 6 Systems-Provide from Water Facilities Inventory(WF+) System Name Mike Beyer Contact Person.Arcadia Drilling he Day Phone:(360 )426-3395 I Cell Phone:( ) Email i Eve Phone:( ) Send results to(Print Fun name.address and zip code cr e-mail) arteta'Sarcacradnuvy corn AND ienniarcadmad-'rg corn SAMPLE INFORMATION Sample collected by(name):Shad Specific location where sample collected Special instructions Or comments BQC048-130 W Doggone Ln Elms Counts please Type of Sample(select only one type of sample from types I through 5 below) 1 0 Routine Distribution Sample(MP) 1, 2 0 Repeat Sample(AN) (from Gstnbubor.system after ursat.movie) Chbnnated Yes __...No Unsatisfactory routine lab number. Chlorine Residual.Total Free__ _ _ _ __ 3 Ground Water Rule Source Sample Unsatisfactory routine collect date 1S1 I _ I — - Chlorinated:Yes No_______ • ❑Triggered(ANP) Chlorine Residual.Total_.___Free ❑Assessment(A,P) 4 Surface or GWI Raw Source Water Sample(Enumeration) 1 S I I I 1,,,..u ❑E.cur( 0 Fecal r 1. s___ ^=-- 5 ®Snnrplle Couected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Conform Present and ____®Satisfactory 0 E cell present ❑E cor absent Bacterial Density Results.Total Col:fam_<1.0 /100m''. E.coli_<l•0 1100m1 Fecal Conform __—_/10CmI HPC_______i1 ml Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0 lab Reference Number o o 25 \w-c�d va50 C2••2 b - o Rex 'Temp C' Method Code —1 .0 SM9223B Date Rax^ed to 20H 04/04/25 Lab Use Orb DCH La:Samples 285-40220 :vN?x,W.••N%V etMM,15.1170404 /V'