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HomeMy WebLinkAboutWAT2025-00111 - WAT Application - 6/30/2025 WAT 2025-00111 MASON COUNTY 415N.6'"Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 _. r. 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 - - Z.,5 Name of Applicant: �, t£ J (, �uv\�^01,in Date: Z Mailing Address: x ✓lt('ii.i �t �?��� w\Phone:• � % 1CR 1-6 t Parcel Number: 22-1 ._Z( J 5 C'C'c 3 Type of Water System Reason for Application C] Public/Community Water System (2 or more [id/ Building permit connections) 0 Division of land: m/ Individual water source(one connection), #of Parcels? SPL I/ Well 0 Boundary line adjustment 0 Spring/surface water ❑ 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 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) 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. ❑ 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:\EH Forms\Thinking 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 11 Water well report(attached to application). Depth + ( 1 ft. t',7 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. li( 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) X 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). -- Reviewer's Signatures: c ^'`k r"'Y'S()44" Environ. Health: Date 6/30/25 This form may be scanned and available for public view at www.masoncountywamov 1'age 2 of 2 =a o& W ARTMENi 01 Notice of Intent No. E59321 —__ WATER WELL REPORT ECO LOGY Unique Ecology Well ID Tag No. BQC151 Type of Work: 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: ❑O Domestic 0 Industrial 0 Municipal Property Owner Name Matthew Chamberlin 0 Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 1501 E Pickering Rd Construction Type: Method: City Shelton County Mason New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool ❑Deepening 0 Other 0 Dug I1],Air- 0 Mud-Rotary Tax Parcel No. 22133-21-50003 Dimensions: Diameter of boring 6 in.,to 117 ft. Was a variance appioved for this well? 0 Yes 0 No Depth of completed well 117 e. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ]W,Wjyl or❑I:WM O I ❑ 6 in 0 i i3 .25 in. LI I 0 0I 0 I.ocation(see instructions on page 2). O I ❑ in _. _ _in. ❑ 1 ❑ ❑ I ❑ NE '/.-Y.of the NW '/;Section 33 Township 21N Range 2W ❑ I ❑ m in. ❑ I ❑ ❑ I ❑ Latitude(Example.47.12345) 47.271505 N ❑ I 0 in. _ _in 0 1 0 ❑ I ❑ Longitude(Example--I20.12345) -122.942803 W Perforations: 0 Yes ®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 r- :' Depth 111 ft. information Use additional sheets if necessary. Screens: fi7 Yes 0 No From To Manufacturer's Name Alloy Machine Works Material Type Stainless slotted Model No. Brown silty sand and gravel 0 16 Diameter 6" Slot size.016 in.from 112 ft to 117 ft. Brown medium sand,gravel 16 35 Diameter Slot size n.from ft to ft. Brown medium sand,gravel,wet 35 72 Sand/Filter pack:O Yes 0 No Size of pack material in Gray silty sand,wet 72 94 Materials placed from_ft.to_ft. Multi-colored gravel,brown medium sand,water 94 117 Surface Seal: ii Yes ❑No To what depth? 19 fi. Material used in seal Bentonite chips _Did any strata contain unusable water? ❑Yes E No Type of water? Depth of strata Mctltotl of sealing strata off _ -- Pump: Manufacturer's Name Type'. ------ H.P. Pump intake depth' ft Designed flow rate, gpm A'ater Levels: Land-surface elevation above mean sea level 213 n. Stick-up of top of well casing 1.5 fl above ground surface Static water level 64 fl.below top of welt casing Date 4/30/25 Artesian pressure lbs.per square inch Date ' Artesian water is controlled by (cap.valve,etc.) Well Tests: Was a pumping test performed? ®No 0 Yes c by who& Yield gpm with ft drawdown after hrs. I Yield gpm with_ft drawdown after hrs. - --- Yield __.___gpm with ft drawdown after Ins. Recovery data(time'zero when pump is turned off-water level measured from well top to water level) ----------------- Time Water level Time Water Level Time Water Level —_ Date of pumping test Bailer test_gpm with_If.drawdown after_hrs. 4/30/25 Air test 20 gpm with stem set at 100 fl.for 1 hrs. - Date Artesian flow gpm - Tetnperature of water 49 "F Was a chemical analysis made? 0 Yes 17 No Start Date 4/30/25 Completed Date 4/30/25 WELL CONSTRUCTION CERTiFICA'FION: 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 Nam Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 4/30/25 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6871. 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 De BQC151 #: Customer: Matthew Chamberlin Well Tage #: Site Address: 1501 E Pickering Rd, Shelton De tth: 117' Date of Test: 5/9/2025 64.9' Pump Set: 100' TIME GPM LEVEL RECOVERY TIME LEVEL 1 Min 4.5 65.6 2 Min 4.5 65.6 1 Min 65.2 3 Min 4.5 65.6 2 Min 65.1 4 Min 4.5 65.7 3 Min 65.1 5 Min 8.1 65.7 4 Min 65 6 Min 8.1 66.1 6 Min 6 5 Min 65 5 7 Min 8.1 66.2 4.9 8 Min 8.1 66.2 9 Min 8.1 66.2 10 Min 12 66.2 15 Min 12 66.9 20 Min 12 66.9 25 Min 12 66.9 30 Min 12 67 35 Min 12 67 40 Min 12 67 45 Min 12 67 50 Min 12 67 55 Min 12 67 1 Hr 12 67 1 Hr 10 Min 12 67 `Total Gallons Pumped: 790.5 I -5! Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 aaaoo�fs� 360-967-7010 v COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected AM Mason 05/09/2025 1 2 D epm Mona Day Year Type of Water System(check only one box) ❑Group A ❑Group B ®Other Group A and Gawp B Systems-Provide from Water Facilities Inventory(WFl): ID# System Name: Matthew Chamberlin Contact Person:Arcadia Drilling.Inc Day Phone:(360 )426-3395 I Cell Phone:( ) Email: 1 Eve.Phone:( ) Send results to:(Print full name,address and zip code or a-mad) arfetaiarcadiadriffin¢oom AND jernaercadadridn6.oam SAMPLE INFORMATION Sample collected by(name).Shad Specific location where sample collected: Special instructions or comments: BQC151-1501 E Pickering Rd.Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1 ❑Routine Distribution Sample(AP) 2.0 Repeat Sample(AIP) Chlorinated:Yes No (from distribution system after ursat routne) Unsatisfactory routine lab number. Chlorine Residual:Total Free — —— ——— — 3.Ground Water Rule Source Sample Unsatisfactory routine collect date. l S l -, Chlorinated:Yes—___No__._-- ❑Triggered(AP) Chlorine Residual Total Free ❑Assessment (AP) 4. Surface or GWI Raw Source Water Sample(Enumeration) S ❑E.cot 0 Fecal Feterea Yes No ` 5.©Sarple Cotected for Information Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifomi Present and (g Satisfactory ❑E.coli present ❑E.coi absent Bacterial Density Results:Total Coliform /100ml E.coli I100m1. Fecal Conform_ _1100m1. HPC __11 ml. Replacement Sample Required: 0 TNTC ❑Sample tco old ❑ Sample Volume ❑Damaged Container ❑ Lab Reference Number 'c�/ Receipt Temp C: Method Code: Ce_O SM9223B Date Reported to DOH Lab Use Only: 05/12/25 DOH Lab-Sample* 285-50912 DOM.row%.3•:312;Ilutea ON IT ore lbbaellernsire tenet a 0127 rOOTT" 1711)