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HomeMy WebLinkAboutWAT2025-00062 - WAT Application - 3/24/2025 WAT ,O- OOO(Pa MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4 Belfair: (360)275-4467 ext 400 v 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: '0-11 / ei)Ge-ti Date: 3—Z-4 Mailing Address: 1,J , j42t,/} !1 F phone: 3(00 - `f v I —9 2 Ci 3 Parcel Number: o a I - 3I 9U 0 u 1 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit BLDAO connections) «<❑ Division of land: 16 Individual water source (one connection), #of Parcels? SPL `4-- Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ 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:\EH Forms\Drinking Water Individual Water Well Water well report(attached to application). Depth 2Z I ft. 5(15(lo 25 pi Well capacity Test(attached to application) I .- • S- qpm T OQ gpd. 6lfflv?S 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. Fif Satisfactory bacteriological test(attach to application). 6(6(?0l5^ Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 141-1 15Q 16n 22n Water use or limitation recorded N/A I:=1 Yes 0 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 • • Part 3: Mason County Community Services Evaluation (staff use only) 7 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. L Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). ✓/�, set Reviewer's Signatures: / OJ O4g Enviro n. Health: Date l(/( `// (� lo?F `NFq,,• 2 of CSD Director: Date 442 DEPARTMENT Of 045 ✓UA/O�� WATER WELL REPORT DEPART Notice of Intent No WE59 ECOLOGY Unique Ecology Well ID Tag No. BQC110 �4 Type of Work: State of Washington 0 I l Construction Site Well Name(if more than one well): ❑ Decommission '- ' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: RI Domestic 0 Industrial 0 Municipal Property Owner Name Rob Hoff ❑Dewatcring 0 Irrigation 0 Test Well ❑Other Well Street Address 323 E Pickering Rd Construction Type: Method: City Shelton County Hl Ncw well El Alteration ❑Di ism ❑Jetted 0 Cable Tool Mason ❑Deepening 0 Other 0 Dug CC Air- 0 hlud-Rotary Tax Parcel No. 22129-31-90001 k Dimensions: Diameter of boring 6 in,to 221 fl. Was a variance approved for this well? 0 Yes ❑' No Depth of completed well 221 ft If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread IA 1 ❑ 6 in. 0 216 .25 in. 118I0 O I ❑ Location(see instructions on page 2): CO WWM or❑EWM ❑ I 0 in _ in. ❑ I ❑ ❑ I ❑ NW '/.-'/.ofthe SW '/.;Section 29 Township 21N Range 2W ❑ I ❑ in — — —inm. p I ❑ in ❑ 1 ❑ DID Latitude(Example:47 12345) 47.27790 N Longitude(Example:-120.12345) -122.96631 W Perforations: 0 Yes lia No Type of perforator used No.of perforations Size of perforations Driller's Log/Construction or Decommission Procedure in.by 1O Formation:Describe by color,character,size of material and structure,and the kind and Perforated from_fl.to_ft.below grounndd surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes 0 No 2 K-Packer Depth 215 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire-wrapped Model No. Fill,brown silty sand and gravel 0 2 Diameter 5_ Slot size.014 in from 216 It to 221 ft Diameter_y Slot size in.front ft.to ft. Brown sandy silt,loose 2 7 Granite,cobbles 7 10 Sand/Filter pack:0 Ycs ❑No Size of pack material in. Brown loose silty sand 10 19 Materials placed from ft.to_ft. Silty sand and gravel,loose 19 37 Surface Seal: 111 Yes ❑No To what depth? 19 ft. Brown coarse sand and gravel,loose 37 58 Material used in seal Bentonite chips Brown coarse sand,wet 58 78 Did any strata contain unusable water? 0 Yes O No Type of water? P 100 Depth of strata Brown coarse sand and gravel with quartz,water 78 Brown and black coarse sand,less gravel,water 100 116 Method of sealing strata off Tan silty sand,water 116 120 Pump: Manufacturer's Name Tyec� Fine black and tan sand,brown silt,water 120 185 TIP._ Pumpintake depth:_ft. Designed blow rate: gP m Gray silty sand with clay and small gravel 185 200 Water levels: land-surface elevation alone mean sea level 221 ft. Gray silty sand,less clay and larger gravel 200 210 Stick-tip of top of well casing 1_5 ft.above ground surface Large sharp gravel,water 210 221 Static water level 90 ft.below top of well casing Date 5/15/25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No 0 Yes ..—? by whom? Yield_gpm with_ft.drawdown after bra. Yield gpm with_ft.drawdown after bus. Yield gpm with_ft.drawdown after hrs. Recovery data(time=zero when pump is tuned off—water level measured from well top to water level) Time Water Level Tinic Water Level Tinto Water level Date of pumping test Bailer test ppm with_ft.drawdown after_hrs. I Air test 50 gpm with stein set at 200 ft.for 1 hrs. Date 5/15/25 Artesian floss gpm J Temperature of water 51 °F Was a chemical analysis made? ❑Ycs g No Start Date 5/13/25 Completed Date 5/15/25 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 O Driller❑Trainee❑PE-Print a c Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/15/25 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. 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: Rob Hoff Well Tag#: BQC110 Site Address: 323 E Pickering Rd, Shelton Depth: 221' Date of Test: 6/5/25 Static: 88' Pump Set: 180' TIME GPM LEVEL RECOVERY 1 Min 3 88.1 TIME LEVEL 2 Min 3 88.2 1 Min 88.95 3 Min 10 88.2 2 Min 88.9 4 Min 10 89.2 3 Min 88.85 5 Min 10 89.3 4 Min 88.8 6 Min 10 89.3 5 Min 88.8 7 Min 10 89.35 6 Min 88.75 8 Min 10 89.35 7 Min 88.7 9 Min 10 89.4 8 Min 88.7 10 Min 12.5 89.4 9 Min 88.7 15 Min 12.5 89.9 10 Min 88.65 20 Min 12.5 90 25 Min 12.5 90.1 30 Min 12.5 90.15 35 Min 12.5 90.2 40 Min 12.5 90.2 45 Min 12.5 90.3 �� 50 Min 12.5 90.3 JON , 7 2025 55 Min 12.5 90.35 1 Hr 12.5 90.4 R 1 Hr 10 Min 12.5 90.5 C&VFQ 1 Hr 20 Min 12.5 90.5 1 Hr 30 Min 12.5 90.55 Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 yex2.17,A y 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 06/05/2025 4 5 DAM PM Abnth Day Yea Type of Water System(check only one box) ❑Group A ❑Group B ©Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Rob Hoff Contact Person:Arcadia Drilling.Inc Day Phone(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results to.(Print full name,address and zip code or a-mail) arteta@arcadadrilling.carn AND jenn@arced.aCnthrg coin SAMPLE INFORMATION Sample collected by(name):Shad Specific location where sample collected: Special instructions or comments: BQC110-323 E Pickering Rd,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1 0 Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AN) (from distrbutton system after unsat routine) Chlorinated Yes _No Unsatisfactory routine lab number. Chlorine Residual:Total Free - - J , 3.Ground Water Rule Source Sample Unsatisfactory routine collect date /V / 2Q2S s I I I RFCF/iikb Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total_._ Free_ ❑Assessment (Ai?) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E.cob 0 Fecal hreren Yes__No 5.I]Sample Collected to Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and XI Satisfactory ❑E.coli present ❑E.cokabsent Bacterial Density Results.Total Coliform /100m1. E.coli_ /100m1. Fecal Cotform ___/100m1 HPC /1 ml Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/Time Received Lab Reference Number 6/6/25 .CD()LQ, l�o Receipt TempCe: Method Code: ode SM9223B Date Reported to DOH Lab Use Only. DOH Lab-Sample# 285-60616 031.3191elkctea t7)•tl yop need M p imoon in In Ylrrolw torntel ai 803 5250127 ITCORTY Cal 711;: 71.sne oew piLiaaaa we aralttle N—don a9 gMtriNapoater