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HomeMy WebLinkAboutWAT2025-00112 - WAT Application - 6/30/2025 WAT 2025-00112 MASON COUNTY 4 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 6/30/25 Name of Applicant: Pinnacle Construction Date: Mailing Address: 1 io w"K"STREET SHELTON,WA 98584 Phone: 360-780-3890 Parcel Number: 520241190140 Type of Water System Reason for Application Ll Public/Community Water System (2 or more 0 Building permit connections) 0 Division of land: ❑ Individual water source (one connection). #of Parcels? SPL O Well 0 Boundary line adjustment ❑ 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. O 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 1:1EH Forms\Drinking Water Revised 05/08/2024 Page I oft Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well f Water well report (attached to application). Depth 44 ft. ® Well capacity Test(attached to application) 20 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. El Satisfactory bacteriological test within last year(attach to application). 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) 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). �h�, Reviewer's Signatures: 6/30/25 Environ. Health: >'�' ' r Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT Of Notice of Intent No. WE59616 �" ECOLOGY Unique Ecology Well 1D Tag No. BQC158 Type of State of Washington ❑ of Work:n Site Well Name(if more than one well). C O Decommission r--> Original installation NO1 No. Water Right Permit/Certificate No. Proposed Use: N Domestic 0 Industrial ❑Municipal Property Owner Name Bobby Sandoval ❑Dcvvatcring O Irrigation ❑Test Well ❑Other Well Street Address 4 W Highland Rd Construction Type: Method: City Shelton County Mason E Ncw well 0 Alteration 0 Driven ❑Jetted 0 Cable Tool Cl Deepening 0 Other ❑Dug o Air- 0 Mud-Rotary Tax Parcel No 52024-11-90140 Dimensions: Diameter of boring 6 in,to 45 ft. Was a variance approved for this well? ❑Yes 0 No Depth of completed well 44 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p 1 ❑ 6 in. 0 44 .25 in. 13 I ❑ l 3 1 0 Location(sec instructions on page 2)i ©WWM or❑EWM O 1 0 in. _ in. ❑ I ❑ LJ I ❑ NE ''V..-1/4 of the NE %;Section 24 Township 20N Range 5W ❑ 1 ❑ in. _ _, in. ❑ 1 ❑ ❑ 1 ❑ ❑ 1 0 in in 0 I 0 0 1 El (Example:47.12345) 47.21291 N . Longitude(Example:-120.12345) -123.24775 W Perforations: ❑Yes tit No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations m.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 ouc entry for each change of Screens: ❑Yes i]No 0 K-Packer mil' Depth It information Use additional sheets if necessary. Manufacturer's Name ------ Material From To Type Model No. Brown silty sand,gravel _ 0 — 6 Diameter Slot size in.from ft.to ft. Brown silty clay with gravel 6 25 Diameter Slot size in from ft.to ft. 25 30 Brown medium sand,few gravels Sand/Filter pack:❑Yes RI No Size of pack material in Brown sandy gravels,water 30 44 Materials placed front ft.to ft Brown stiff silty clay 44 45 Surface Seal: ill Yes ❑No To what depth? 18 fi Material used in seal Bentonite chips Did any strata contain unusable water? 0 Yes ©No Type of water? Depth of strata Method of sealing strata oft' I Pump: Manufacturer's Name Type' IIP._ Pump intake depth:_ft Designed flow rate: gpm Water Levels: land-surface elevation above mean sea level 327 ft. Stick-up of top of well casing 1.5 ft.above ground surface Static water level 14 ft.below top of well casing Date 5/19/25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? a❑No 0 Yes r-> by whom? Yield gpm with_fi drawdown atter lies. Yield gpm with ft drawdown after inns. Yield gpm with_ft.drawdown after hrs. Recovery data(time=zero when pump is turned off- water level measured front well top to water level) Time Water Level Time Water Level Time Water level Date of pumping test Bailer test_gpm with_ft.drawdown after_has. Air test 20 gpm with stem set at 40 ft,for 1.5 brs. — Date 5/19/25 Artesian flow gpm Temperature of water 50 °F Was a chemical analysis made? 0 Yes Fl No Start Date 5/19/25 Completed Date 5/19/25 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 LI Driller 0 Traine F.-P amc James Johnson Drilling Company Arcadia Drilling Inc. Signature �.� Address PO Box 1790 License No. 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2874 Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/19/25 ECY 050-1-20(Rev 09/I8) If you need this document it: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: Bobby Sandoval Well Tag#: BQC158 Site Address: 4 W Highland Rd, Shelton Depth: 44' Date of Test: 6/17/25 Static: 15' Pump Set: 35' TIME GPM LEVEL RECOVERY 1 Min 5.3 15.9 TIME LEVEL 2 Min 5.3 15.95 1 Min 15 3 Min 5.3 15.95 4 Min 5.3 15.95 5 Min 13 15.95 6 Min 13 18 7 Min 13 18.4 8 Min 13 18.4 9 Min 13 18.45 10 Min 13 18.5 15 Min 13 18.55 20 Min 13 18.6 25 Min 13 18.7 30 Min 13 18.7 35 Min 13 18.75 40 Min 13 18.8 45 Min 13 18.9 50 Min 13 18.9 55 Min 13 18.9 1 Hr 13 18.9 1 Hr 10 Min 13 18.9 Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 v�®veal 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected MASON 06117I2025 r o'�' _1§7f1 P.brN Day Yea, - Type of Water System(check only one box) ❑Group A ❑Group B ©Otter Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: BOBBY SANDOVAL 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 e.maiq arietagarcad,adriting.cam AND iennalarcadiadrilling.corn SAMPLE INFORMATION Sample cofected by(name):Shad Specific location where sample collected: Special instructions or comments: 4 W Highland Rd, Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2.0 Repeat Sample(NP) Chlorinated:Yes No (from distribution system atter unsat rouunel Unsatisfactory routine lab number. Chlorine Residual:Total—_Free__- 3.Ground Water Rule Source Sample Unsatisfactory routine collect date S I 1— I Chlorinated:Yes No ❑Triggered(A'P) Chlorine Residual:Total_Free_ ❑Assessment (A,P) 4. Surface or GWI Raw Source Water Sample(Enumeration) f S ❑E.coil ❑Fecal Fterel Yes .. No 5.I]Sarple:ollectec`cr Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and 12 Satisfactory 0 E cell present ❑E.coli absent Bacterial Density Results:Total Coliforn /100m1. E.coli 1100m1 Fecal Colifonn _J100m1 HPC /1 ml Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ _,__ Daterrre R eived: Lab Reference Number ,(2k% ItS (l0'•00 V-250 21 -i Y Receipt Temp C°: Method Code. Lk° SM9223B Dale Raperted tc DOH tab'ise Only 06/19/25 DOH Las—Sample; 285-61 81 8 UGH�trn RU+.Jrrl a�OB,T.rtyou roa7ft,sPt+u7mnan.>ifvrWq kxrot�id005250,2'!Tc.r.rrxr lr7,)