HomeMy WebLinkAboutWAT2025-00123 - WAT Application - 6/9/2025 WAT202S - C)6
MASON COUNTY 415 N.6th 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
Name of Applicant: Kevin Klein - Go Feasibility Date: 6-9-25
Mailing Address: P.O. Box 1176, Sumner, WA 98390 Phone: 206-219-0565
Parcel Number: 322247600030
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more it Building permit d 2025 CX)-1 i �P
connections) ❑ Division of land:
iIndividual water source (one connection), #of Parcels? SPL
Well ❑ 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.: 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
I I:I I 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
X Water well report(attached to application). Depth 397 ft. 4// l /70 7 s
Well capacity Test(attached to application) 10• 2 5 gpm 6 3 gpd. Y<«(tozS
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.
Satisfactory bacteriological test within last year(attach to application). Y(` l 7 70 ci✓
Individual Spring/Surface Water
O 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 resou a regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040,Drei9rmipafion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements ma9'ippl ;,...ctrapter
36.70A RCW. s )i, ( r ,_.
Unsatisfactory Determination: JU
Applicant's water supply does not appear adequate to meet the needs of its intended uaF,Je follo�i �Q t.
reason(s). e�
NryF,yy-,
�RoN�'r1E
Reviewer's Signatures: / '} 1)41S NTg4 k.
Environ. Health: Date 7( 7/ 10 (�
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT lim DEPARTMENT OF Notice of Intent No.WE58756
410- ECOLOGY Unique Ecology Well ID Tag No.BPS-171
Type of Work: State of Washington
E Construction Site Well Name(if more than one well):
0 Decommission r--) Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: E Domestic ❑Industnal ❑Municipal Property Owner Name George Eqqiman do Go Feasibilty
❑Dewatenng 0 Irrigation ❑Test Well ❑Other
Well Street Address 110 NE Bear Ridge Rd
Construction Type: Method:
E New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Betfair County Mason
❑Deepening 0 Other ❑Dug ®Air- ❑Mud-Rotary Tax Parcel No.32224-76-00030
Dimensions: Diameter of boring 6 in.,to 399 ft. Was a variance approved for this well? 0 Yes E No
Depth of completed well 397 ft.
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
E I ❑ 6 in. +1_2 397 in SID 0 I 0 Location(see instructions on page 2): E WWM or 0 EWM
❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ NW 1/4-1/4 of the NW'/;Scction 24 Township 22N Range 3W
❑ I 0 in. _ in. ❑ I ❑ ❑ 1 ❑
❑ 1 ❑ in _ _ in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.38787
Longitude(Example:-120.12345)-123.00987
Perforations: ❑Yes E No Type of perforator used
No.of perforations Size of perforations in.by in. Drillers Log/Construction or Decommission Procedure
Perforated from ft.to ft.below ground surface Formation:Descnbe by color,character,size of material and structure,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: ❑Yes E No ❑K-Packer => Depth ft. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No.
Diameter Slot size in.from ft.to ft. Lt Brown glacial till 0 9
Diameter Slot size in.from ft.to ft. Tan cobbles gravel silty sand 9 28
Lt brown cobbles gravel sand clayey silt saturated 28 70
Sand/Filter pack:❑Yes E No Size of pack material in. Lt grayish brown gravel silty sand 70 82
Materials placed from ft.to ft. Lt grayish brown cobbles gravel sand clayey silt 82 130
Surface Seal: E Yes ❑No To what depth?18 ft. Lt brown gravel silty sand 130 149
Material used in seal BENTONITE CHIPS Lt brown gravel sand clayey silt 149 153
Did any strata contain unusable water? ❑Yes El No
Type of water? Depth of strata Lt brown gravel sand silt loose 153 183
Method of sealing strata off Lt brown silty clayey sand 183 213
Lt brown trace gravel silty clayey sand 213 222
Pump: Manufacturer's Name Type: Lt brown gravel silty sand 222 234
H.P. Pump intake depth: ft. Designed flow rate gpm Lt brown cobbles gravel sand silt loose 234 251
Water Levels: Land-surface elevation above mean sea level ft Lt brown gravel sand clayey silt saturated 251 312
Stick-up of top of well casing+1.2 ft.above ground surface Lt grayish brown gravel sand silt 312 329
Static water level 350 ft.below top of well casing Date 04/01/2025
Artesian pressure lbs.per square inch Date Lt grayish brown gravel sand silt 329 333
Artesian water is controlled by (cap,valve,etc.) Lt gray silt 333 372
Lt gray gravel sand silt water 372 397
Well Tests: Lt gray gravel sand clay 397 399
Was a pumping test performed? 21 No ❑Yes c=5 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)
Time Water Level Time Water Level Timc Water Level
Date of pumping test
Bailer test gpm with_ft drawdown after hrs.
Air test 15 gpm with stem set at 395 ft.for 1 hrs. - Date 04/01/202,5
Artesian flow gpm _
Temperature of water °F Was a chemical analysis made? ❑Yes E No Start Date 03/28/2025 Completed Date 04/01/2025
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.
E Driller❑Trainee❑PE—Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING
Signature ,`✓ C/- Address PO BOX 44427
License No.2432 City,State,Zip TACOMA,WA 98448
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.RICHAW"3210B Date 04/02/2025
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.
RICHARDSON WELL DRILLING
Aquifer Test Data 64
Well ID# BPS-171 Owner: George Eggiman Go Go Feasibility
A vwufr: 10, 2f G 1)r71
Site Address: 110 NE Bear Ridge Rd `Mq l : 6(3.5 941
Pumping Well Parcel#: 32224-76-00030
Pump On 04/17/25 14:40 Pump Off 04/17/25 15:40
Date Time Date Time
Reference Static Level 349.70 Feet Pump Size 1.5 HP Pump 10 GPM/3HP Motor
Recorded By Time Water Levels
Date Clock Elapsed Time Reading In Depth To Drawdown COMMENTS
Since Start Gpm Water
4/17/2025 14:40 0:00 3 349.70 0.00
14:42 0:02 3 350.20 0.50
14:44 0:04 3 350.20 0.50
14:46 0:06 3 350.20 0.50
14:48 0:08 3 350.20 0.50
14:50 0:10 3 350.20 0.50
14:55 0:15 5 350.40 0.70
15:00 0:20 5 350.40 0.70
15:05 0:25 6.5 350.50 0.80
15:10 0:30 10 350.70 1.00
15:15 0:35 10 350.80 1.10
15:20 0:40 15.5 351.30 1.60
15:25 0:45 15.5 351.30 1.60
15:30 0:50 20 351.50 1.80
15:35 0:55 20 351.70 2.00
15:40 1:00 20 351.70 2.00
RECOVERY 15:41 1:01 351.50 1.80
15:42 1:02 351.00 1.30 .
15:43 1:03 351.00 1.30
15:44 1:04 350.90 1.20
15:45 1:05 350.90 1.20
j.
„ `' • Al i:R
IM MANAC;I:MLNT
MIL 1_A130RATORI LS trit..
- t515 Both St E, Tacoma.WA 98404
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Corrected Time Sample County
Collected
"T J 1 / 'Z i � p�u' MQsc,'1
-_ au
ir Day ,ea'
~ 6hv Type of Water System(check only one box)❑Group A ❑Group B 1(J�(
Other ' T
rGroup A and Group B Systems-Provide from Water Facilities Inventory(•WFI):
System Name. E 0,4.I KG✓rn
contact pew: Aaron Richardson
Day Phone:(253) 537-7332 I Cell Phone:l 253) 377-0236
Email: t Eve.Phone:( 1
Send results to(Pnnt lull name.address and m cadet
Richardson Well Drilling __
PO Box 44427
Tacoma, WA
98448
SAMPLE lIFORNATION
Sample collected by(name): 0 'Go
Speafic location where sample t: ) Special instructions or comments:
' 10 NE f eCO
' Type of Sample(select only one type of sample from types 1 through 5 below)
i 1 outine Distribution Sample(A/P) 12 ❑ Repeat Sample(A/P)
f•,T csrt system a`e,unsat routine)
Chlorinated,Yes No
Unsatisfactory routine lab number
Chlorine Residual:Total__-Free_
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
S 1 1 !
Chlorinated Yes No
❑T-ggered(A'P) Chlorine Residual:Total_Free_
❑Assessment (A/Pi
4. Surface or MI Raw Source Water Sample t Enumeration; I $ I I
❑E.cob ❑Fecal ..
1 5.❑Samp.Calected for IA/melon OW LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colifonn Present and Satisfactory
G.-= present 0 E.coli absent
-c:
Bacterial Density Results Total Coldomi 100mi E coe____ . /100m1.
Fecal Coliform_ -_ `100m1 HPC - - 1 ml
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container ❑e'T.me Recened ,e77Cr-----)yt46lab Re* rii d /e
Receipt Temp C. frfeelod Coact. ? �� 1
Date Riwnea m DOH Lab use Orly-AR 18 3 R
1 C2-d-S
DOH La.-Samples ,
089 13761 .
!:!1Hh-.at3t 3:9 va._n..an'n .+rtu mil ere atocr'n •*was.i rt dt0ou507:1;;1 rtt`ran 71.
'4,as:Tv x,.rm'^4 re a.aUO.r.+.x wW.' +yMw
;WATER 1513 Bath St. E.
AI MANAGEMENT Tacoma, WA 98404
"Mk LABORATORIES INC. (253) 531 3171
Nitrate/Nitrite
Report of Analysis
Date Collected: 04-17-2025 System Group Type (circle one) A B Other
Water System ID Number: N/A System Name: Eggiman, Kevin
Lab Number/Sample Number: 089/02409 County: Mason
Sample Location: 110 NE Bear Ridge Rd, At Wellhead Source Number(s): (list all sources if blended or composited)
Sample Purpose: (check appropriate box) Date Received: 04-18-2025
® RC - Routine/Compliance(satisfies monitoring requirements) Date Analyzed: 04-18-2025
C -Confirmation(confirmation of chemical result)* Date Reported: 04-25-2025
• I - Investigative (does not satisfy monitoring requirements) Supervisor Initials: L/
O 0 -Other(specify-does not satisfy monitoring requirements)
Sample Composition: (check appropriate box) Sample Type: (check one) ® Pre-treatment/Untreated(Raw)
S - Single Source Post-treatment(Finished)
B - Blended (list source numbers in"Source Number"field) Unknown or Other
C - Composite(list source numbers in"Source Number"field) Sample Collected by:Dylan
D- Distribution Sample Phone Number 253-537-7332
Send Report & Bill to: Richardson Well Drilling Comments:
PO Box 44427
Tacoma WA 98448
ANALYTICAL RESULTS
DOH# ANALYTE DATA RESULTS SDRL TRIGGER MCL UNITS EXCEEDS METHOD!
QUALIFIER MCL? INITIALS
0020 Nitrate as N -- 0.23 - 0.5 5.0 10,0 mq/L No 300.0/CP
NOTES:
Confirmation: Include the original lab number, sample number, and collection date of original sample in either comment section
—No exisiting value.
ANALYTE: The name of an analyte being tested for.
DATA QUALIFIER: A symbol or letter to denote addtional information about the result.
DOH#: Department assigned analyte number.
EXCEED MCL: (Maximum Contamination Level): Marked if the contaminant amount exceeds the MCL under chapters 246-290
and 246-291 WAC. Please contact the department's drinking water regional office in your area to determine follow-up actions.
METHOD/INITIALS: Analytical method used. / Initials of the analyst that performed the analysis.
mg/L: milligrams per liter or parts per million
RESULT: The laboratory reported result.
SDRL: (State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the Department
of Health
TRIGGER: The department's drinking water response level. Systems with contaminants detected at concentrations in excess of
this level may be required to take additional samples or monitor more frequently. Please contact the department's drinking water
regional office in your area for further information.
LAB COMMENTS: