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Home My WebLink AboutWAT2025-00132 - WAT Application - 6/24/2025 WAT go s - Do/3,- MASON COUNTY 415N.611'Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 « `z'1 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 Name on Applicant: 740 )711.1 0/Z, Date: 6 - zy-- z3)- Mailing Address: 45 q S5-firpit Phone: 3 )-- /SS Parcel Number: 3 /t./ - /�D D Zc) Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 1 Building permit BLD OO�-007690 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL (g Well ❑ Boundary line adjustment 0 Spring/surface water 0 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 J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 • Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well f—Water well report (attached to application). Depth i; 9 ft. !sirWell capacity Test(attached to application) 'S U gpm �� `�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. NJI 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). Reviewer'sY Signatures: Environ. Health: CEa ' I Date 7I(k'/t '?S_ This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 ....- WATER WELL REPORT ...Km DEPARTMENT OF NoticeoflntentNo. WE58833 i ECO LOGY Unique Ecology Well ID Tag No. BQL 680 Type of Work: State of Washington E Construction Site Well Name(if more than one well): ❑ Decommission => Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: E Domestic ❑Industrial 0 Municipal Property Owner Name Smith Back Forty Lic ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address xx SE Ellis Rd Construction Type: Method: O New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug lE Air- 0 Mud-Rotary Tax Parcel No. 31904-14-90020 Dimensions: Diameter of boring 6 in.,to 140 ft. Was a variance approved for this well? ❑ Yes E No Depth of completed well 139 ft. If yes,what was the variance for'? Construction Details: Wall ('axing Liner Diameter From To thickness Steel PVC Welded Thread E ❑ 6 in. +1 139 .25 in. l J I 0 ❑ I ❑ Location(see instructions on page 2): t J WWM or❑EWM O C in. in. ❑ ❑ ❑ I ❑ SE 'h-'hofthe NE 'h;Section 04 Township 19N Range 03 ❑ ❑ in. in. ❑ I ❑ ❑ I ❑ ❑ ❑ in. _ _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.16625 Longitude(Example:-120.12345) -123.05841 Perforations: 0 Yes r•No Type of perforator used t \o.of perforations Size ofperforntions in.by_in. Drillers Log/Construction or Decommisawu Procedure Formation:Describe by color,character.size of material and structure,and the kind and ' Perforated front R.to ft.below y�ound surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑Yes li]No C K-Packer => Depth_ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter in. Slot size_ in.from ft.to It. Top soil,gravel 0 1 Diameter in. Slot size_ in.from_ft.to_R. Sand,silt,some gravel,soem clay,brown/soft 1 7 Sand,silt,some gravel,brown/soft 7 26 Sand/Filter pack:0 Yes a❑No Size of pack material in. Sand,gravel,silt,brown/soft 26 74 Materials placed from ft.to ft. Sand,silt,gravel,siltbound,brown/hard 74 86 Surface Seal: C Yes ❑No To what depth? 18 ft. Clay,silt,little sandy,brown/hard 86 93 Material used in seal Bentonite Granular Did any strata contain unusable water? ❑Yes IPJ No Clay,silt,gray/hard 93 117 Type of water? Depth of strata Clay,silt,sand,gravel,gray/soft 117 124 Method of sealing strata off Sand,gravel,silt,gray/soft,wb 124 132 Sand,gravel,silt,gray/soft,more water,wb 132 140 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 +1 ft.above ground surface Static water level 81 ft.below top of well casing Date 3/18/2025 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ❑O No ❑Yes t' by whom? Yield _gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Yield_gpm with_ft.drawdown atter hrs. 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 — Railer test_gpm with_R.drawdown after_hrs. Air test 50 gpm with stem set at 137 fl.for 1 hrs. - Date 3/18/2025 Artesian flow_gpm — Temperature of water °F Was a chemical analysis made? 0 Yes ❑a No Start Date 3/18/2025 Completed Date 3/18/2025 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. ID Driller 0 Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature C '64_ ` ""L1k1." _ 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 3/18/2025 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 7l I for Washington Relay Service. Persons with a speech disability can call 877-833-6391. -Taal SM It A-11 • Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANGUAP i�J Report of Laboratory Analysis LABORATORY Collected by: Moerke and Sons Matrix Drinking Water 360-748-3805 Laboratory ID: V250423-9 Sampling Address: Date Sampled: 4/23/25 13:00 Southeast Ellis Road Date Received: 4/23/25 13:30 Shelton,WA 98584 Date Reported: 4/25/2025 Sample ID: Southeast Ellis Road Analysis Result SDRL, MCL Units DF Date Analyzed Total Coliform& E.coli by SM 9223B(IDEXX) Batch ID:V250423-9 Analyst:AF Coliform,Total Negative 1 1 MPN/100 mL 1 4/23/25 16:05 E.coli Negative 1 1 MPN/100 ml, 1 4/23/25 16:05 Nitrate by Hach Method 10206 Batch ID:V250423-9 Analyst:KS Nitrate(as N) 0.506 0.50 10.00 mg/L 1 4/23/25 17:00 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/25/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 04/25/2025 DF:Dilution Factor '�r` 17025:2017 �� eccsenrren MCL:Maximum Contaminant Level �� usoruroRx 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 Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com 1of1