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HomeMy WebLinkAboutWAT2025-00104 - WAT Application - 5/21/2025 WATaD - ccAD4 . :. MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 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: l'rcrrv'y _Ken Sclt�141 Date: 5/A I/j&o c •J jhe(t r l 1,�� Mailing Address: Po e c,, 14 9 qs, • Phone: (330) 0 l' 91/3 Parcel Number: 3'? O 3 3 —{ / — `7 D/0 c Type of Water System / 'Reason for Application ❑ Public/Community Water System (2 or more [� Building permit U i 5-Oo(•24 / connections) 0 Division of land: Li Individual ter source (one connection), #of Parcels? SPL 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. ❑ 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.: creational to full time). Please indicate on the following line the nature of this change: This water system is a 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:AHi Forms\Drinking Water Revised 1/25/2018 Individual Water Well /Water well report(attached to application). Depth II L ft. IJ Well capacity Test(attached to application) /.a , 5- gpm ? °-u 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. It/Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14= 15= 16n 22= Water use or limitation recorded N/A 0 Yes 1-1 Well Drilled Date 7/l c/ Z 2- 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) k'( 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). �eviewer's Signatures: Environ. Health: l( 711\-01\1\f' Date ((7/ 1-k< 2°t 2 CSD Director: Date WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE47767 ECOLOGY Unique Ecology Well ID Tag No. BNV870 Type of Work: �i State of Washington Site Well Name(if more than one well): O Construction ❑ Decommission ==> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use Domestic 0 Industrial 0 Municipal Property Owner Name RiCk Schmelina • 0 Dewatering ❑Irrigation ❑Test Well 0 Ot1C` Well Street Address 740 SE Binns Swiqer Loop Rd Construction Type: Method: City Shelton County Mason El New well 0 Alteration ❑Driven ❑Jetted ❑Cable Tool ❑Deepening ❑Other ❑Dug GI Air- ❑Mud-Rotary Tax Parcel No. 32033-11-00000 Dimensions: Diameter of boring 6 in.,to 135 ft. Was a variance approved for this well? 0 Yes E No Depth of completed well 134 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ❑. WWM or❑EWM O I ❑ g in 0 131 .025 in. alp I] I ❑ Location(see instructions on page 2): ❑ 1 ❑ in. _ in. ❑ 1 ❑ ❑ 1 ❑ NE 'h-'/.of the SE '/.;Section 33 Township 20N Range 3W ❑ 1 ❑ in. _ — in. ❑ I ❑ DID❑ I 0 in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.185159 N Longitude(Example:-120.12345) -123.055569 W Perforations: ❑Yes O No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations_in.by in_ Formation:Describe by color,character,size of material and structure,and the kind and Perforated from—ft.to ft below ground surface nature of the material in each layer penetrated,with at least one entry for each change of ©K-Packer " Depth 128 ft. information. Use additional sheets if necessary. Screens: ®Yes 0 No From To Manufacturer's Name Alloy Machine Works Material Type Wire Wrapped Model No. grown fine to medium sandy gravel,silt bound, 0 I Diameter 5 Slot size.010 in.from 129 ft.to 134 1I 47 tight,dry Diameter Slot size in.from —ft.to—ft- Brown medium sand,loose,moist 47 51 Sand/Filter pack:0 Yes O No Size of pack material in Brown fine to medium sandy gravel,silt bound, 51 Materials placed from ft.to_ft. tight,dry 72 Surface Seal: ii Yes 0 No To what depth" 20 ft. Black fine sandy gravel with gray clay,binding, 72 Material used in seal Bentonite Chips tight,dry 74 Did any strata contain unusable water? ❑Yes h7 No Blue clay,stiff,dry 74 85 Type of water? Depth of strata Black medium sandy gravel,gray clay,binding. 85 Method of sealing strata off tight,dry 101 Pump: Manufacturer's Name Type: Black small gravelly silt,active,wet 101 105 H.P. Pump intake depth:_ft. Designed flow rate: gpm Gray clay,stiff,dry 105 117 Water124 ft Black medium to coarse sandy gravel, 117 Levels: Land-surface elevation above mean sea level 130 Stick-up of top of well casing 1.5 ft.above ground surface tight,water bearing Static water level 36 ft.below top of well casing Date 7/18/22 Artesian pressure lbs.per square inch Date Black coarse sandy gravel,loose,water 130 136 136 136 (cap,valve,etc.) Gray clay,stiff,dry Artesian water is controlled by ( P• Well Tests: Was a pumping test performed? E7 No 0 Yes r > 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) Water Level Time Water Level Time Water Level Time Date of pumping test Bailer test gpm with_ft drawdown after_hrs. Air test 30 gpm with stem set at 120 ft.for 1 hrs. Date 7/18/22 Artesian flow_gpm Temperature of water 51 °F Was a chemical analysis made? 0 Yes f]No Start Date 7/18/22 Completed Date 7/18/22 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. 0 Driller 0 Trainee 0 PE-Print t i e 1,..e hythian Drilling Company Arcadia Drilling Inc. / Address PO Box 1790 Signature License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 7/18/22 ECY 050-1-20(Rev 09/18) 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: Jeremy Oehlenschlager Well Tag#: BNV870 Site Address: 91 SE Campfire Ct, Shelton Depth: 134' Date of Test: 2/21/25 Static: 34.7' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 15.5 35.6 TIME LEVEL 2 Min 15.5 36.3 1 Min 35 3 Min 15.5 36.4 2 Min 35 4 Min 15.5 36.5 3 Min 35 5 Min 15.5 36.5 6 Min 15.5 36.6 7 Min 15.5 36.6 8 Min 15.5 36.6 9 Min 15.5 36.7 10 Min 15.5 36.7 15 Min 15.5 36.7 20 Min 15.5 36.7 25 Min 15.5 36.8 30 Min 15.5 36.8 35 Min 15.5 36.8 40 Min 15.5 36.8 45 Min 15.5 36.8 50 Min 15.5 36.8 55 Min 15.5 36.9 1 Hr 15.5 36.9 Thurston County Environmental Health 412 Lilly Rd NE to Olympia,WA 98506 -.--�-- 360 867-2631 THURSION COUNTY --COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected 2 1 2s air AM :"3 v o PM I'� Month Day Year Type of Water System(check only one box) (Private Household LI Group A ❑Group B ❑Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: j j e_re,,r'►1v1 `1��1 /1 S C tAt t�`W Day Phone:( ) J Cell Phone:�('3 30 ) Cq 7 9w 73 E-mail:' k r t� Eve. hone:( ) l7l.� C1��hlry� f Mc� : nor{{ �f 1 t Send results to: P t full name, ddress and zi code or ea#ail address 3 e.4—[ S l — S ,I vn vvA --1_SAM SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample c ected: Special instructions or comments: 5 Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total_Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coil—GWR(A/P) ['Fecal—Surface,GWI,springs(numeration) Unsatisfactory routine lab number: • Filtered:Yes No ❑Assessment Monitoring(A/P) , Unsatisfactory routine collect date: ['Other S 4.r Sample Collected for Information Only / Investigative Construction/Repairs `I Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑E.coli absent o liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Cod:�/I.SM 9223B ❑SM 9222D Date and Time Received2. 4 • SM 9215B ❑Enterolert® Z—1.2'15 0803 Date and Time Analyzed: L — t 2 Date Report) - jf .A- Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0