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Home My WebLink AboutWAT2025-00106 - WAT Application - 5/20/2025 IWAT _00106 I 415 N.6th Street ��w""''? •L liti Shelton,WA 98584 C MASON COUNTY Shelton:360-427-9670,Ext.400 t�`Ili" COMMUNITY SERVICES Belfair:360-275-4467,Ext.400 y Elma:360-482-5269,Ext.400 av- Building,Planning,Environmental Health,Community Health 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 Sold Name on Applicant: By Sarno LLC Date: 05/20/25 Mailing Address: 2039 S 304th St Federal Way,WA 98003 Phone: (253)359-1505 Parcel Number: 520017690023 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ■ Building permit • connections) 0 Division of land: II ■ Individual water source (one connection), #of Parcels? SPL ■ Well 0 Boundary line adjustment iI ❑ 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: I, (write"none"for two-party) I I 0 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. j I Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. Revised 4/4/2018 J:\EH Fomu\Drinking Water Individual Water Well I Water well report(attached to application). Depth 99 ft. • Well capacity Test(attached to application) 60 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 a well cca ac ty test,which provides dethe s stabilization ofd draw-down anddoes recovery data, must be performed p Y 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 1516 22 Water use or limitation recorded N/A Yes Well Drilled . Date 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 -- I • • 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. E Unsatisfactory Determination: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Al(kkritYvetwl- Date 6/18/25 Environ. Health: This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of WATER WELL REPORT .. DEPARTMENT OF Notice of Intent No. WE59145 ECOLOGY Unique Ecology Well ID Tag No. BRR 103 Type of Work: State of Washington Site Well Name(if more than one well): Construction Decommission q Original installation NOI No. Water Right Permit/Certificate No. I Proposed Use: E Domestic 0 Industrial Municipal Property Owner Name Sold By Samo Dewatering 0 Irrigation 0 Test Well C Other Well Street Address 80 W Grizzly Rd Construction Type: Method: City Shelton County Mason E New well Alteration Cl Driven 0 Jetted 0 Cable Tool C Deepening C Other ❑Dug E Air- 0 Mud-Rotary Tax Parcel No. 52001-76-90023 Dimensions: Diameter of boring 6 in.,to 100 ft. Was a variance approved for this well? 0 Yes I]No Depth of completed well 99 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ead 0 WWM Or❑EWM • I ❑ 6 in. +1 99 .25 in. CI I 0 0 j Location(see instructions on page 2): • 1 ❑ in. _ in. ❑ 1 ❑ OIC SW 'Yr-1/4 of the SW '/;Section 01 Township 20N Range 05 ❑ 1 ❑ in. 1° ❑ 1 ❑ ❑ I ❑ Latitude(Example:47.12345) 47.24505 O I 0 in. — in. ❑ I ❑ ❑ 1 ❑ Longitude(Example:-120.12345) -123.26310 Perforations: 0 Yes E No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforat ions m by_in Formation Describe by color,character,size of material and structure,and the kind and Perforated from_fl.to ft.below ground surface nature of the material in each layer penetrated.with at least one entry for each change of Screens: 0 Yes ll No ❑K-Packer Depth ft. information. Use additional sheets if necessary. Manufacturer's Name___. Material From To Type Model No. Top soil 0 1 Diameter_ in. Slot size_ in.from_ft.to_ft. Sand,gravel,some silt,brown/soft 1 6 Diameter in. Slot size_ in.from_ft.to ft. 6 19 Sand,gravel,silt,brown/soft Sand/Filter pack:❑Yes P No Size of pack nuatcr al M. Sand,gravel,silt,some clay,brown/hard 19 86 Materials placed from_ft to ft. Sand,gravel,silt,brown/hard,wb 86 100 Surface Seal: E Yes 0 No To what depth? 18 ft. Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes Oa 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 f1 ft.above ground surface Static water level 42 ft.below top of well casing Date 3/26i2025 Artesian pressure_ lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? fEi No C 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 top to water level) Tine Water level Time Water Level Time Water Level Date of pumping test Bailer test gpm with_ft drawdown after_his.~ _ - Air rest 60 m lea, gpm with stein set at 97 A.for 1 S. `- Date 3/26/2025 Artesian flow_gpm Temperature of water °F Was a chemical analysis made? ❑Yes g No Start Date 3/26/2025 Completed Date 3/26/2025 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. Driller C Trainee C PE-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature C 'TLfw%. t.- 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 3/26/2025 ECY 050-1-20(Rev 11/18) if you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Vanguard Laboratory 2635 Parkmont Lane SW k , . Olympia,WA 98502 ® 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY k Collected by: Matrix Drinking Water Moerke and Sons Laboratory ID: V250401-7 360-748-3805 Date Sampled: 4/1/25 13:00 Sampling Address: Date Received: 4/1/25 14:07 80 West Grizzly Ridge Rd Date Reported:4/3/2025 Shelton,WA 98584 Sample ID: 80 West Grizzly Ridge Rd Result SDRL MCL Units DF Date Analyzed Analysis Batch ID:V250401-7 Analyst:AF Total Coliform&E.coli by SM 9223B(IDEXX)I I MPN/100 mL 1 4/1/25 16:38 Negative Coliform,Total g ative E.coli I MPN/100 mL I 4/1/25 16:38 Negative i Batch ID:V250401-7 Analyst:KS Nitrate by Hach Method 10206 10.00 mg/L 1 4/1/25 16:18 Nitrate(as N) ND 0.50 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/03/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 04/03/2025 DF:Dilution Factor ift; `- l7112¢:2017 S`� MCL:Maximum Contaminant Level �r., �►ecaSrrsv thouff 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 I.n SW,Suite A.Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com Iofl