HomeMy WebLinkAboutWAT2025-00166 - WAT Application - 8/18/2025 !IV t1 1 LULU UU t UU
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COMMUNITY SERVICES
4 i Building.Manning,Environmental Health Community Health
415 N 6th Street. Bldg 8, Shelton WA 98584.
Shelton. (360)427-9670 ext 400 s• Belfair: (360)275-4467 ext 400 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.
14. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: G j1/'/5 we 5 Rao r Date: 'Y//b'/ Z c
Mailing Address: l47 Z 7Ilf L >{ -A-A R0/ D Phone: 3& 0 _C '1e` ?4 Z
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.7
Parcel Number: 2, z o q c90 / 10
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more jet(Building permit
connections) 0 Division of land:
Individual water source (one connection), #of Parcels? SPL
0 Well 0 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
is\1rH Foetus\Annking Water Revised 1/25/20 t 8
Individual Water Well
IX Water well report (attached to application). Depth f 3 7- ft.
9(Well capacity Test (attached to application) i6 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.
7( Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA httoi/gi .co.masOn.wa.usiplanning 14_ 15 16 22
I
Water use or limitation recorded N/A Yes
Well Drilled ... . Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
O 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)
1 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:
Environ. Health: �S 9/22/25
Date
CSD Director: Date 2"` ,
WATER WELL REPORT DEPARTMENT OF Notice of Intent No.WE59311
ECOLOGY Unique Ecology Well ID Tag No.BPS-181
Type of Work: State of Washington
® Construction Site Well Name(if more than one well):
❑ Decommission ==> Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: El Domestic 0 Industrial 0 Municipal Property Owner Name Chris Weishaar
0 Dewatering 0 irrigation ❑Test Well ❑Other Well Street Address XXX Munson Ct
Construction Type: Method:
E New well ❑Alteration 0 Driven 0 Jetted ❑Cable Tool City Belfalr County Mason
0 Deepening 0 Other 0 Dug El Air- ❑Mud-Rotary Tax Parcel No.22309-76-00170
Dimensions: Diameter of boring 6 in.,to 137 ft. Was a variance approved for this well? 0 Yes ®No
Depth of completed well 137 ft.
if yes,what wasthe variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
® I 0 6 in. +1_2 137 in. ® I ❑ ❑ I ❑ Location(see instructions on page 2): ®W WM or 0 EWM
❑ I 0 in. in. ❑ I ❑ CIO NE '''A-1/4 of the 5.5'/;Section 9 Township 23N Range 2W
❑ I ❑ in. _ in ❑ I ❑ ❑ I CI
ID I ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345)47.49792
Longitude(Example:-120.12345)-122.93007
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
Screens: 0 Yes El No E K-Packer Depth ft. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No. Lt brown cobbles gravel sand clay 0 2
Diameter Slot size in.from ft.to ft
Diameter Slot size in,from ft.to ft Lt gray boulders cobbles gravel silty clayey sand 2 22
Lt brown cobbles gravel silty sand 22 47
Sand/Fitter pack:❑Yes El No Size of pack material in Grayish brown gravel silty sand 47 82
Materials placed from ft to ft. Lt brownish gray gravel silty clayey sand wet 82 94
Surface Seal: lid Yes 0 No To what depth?18 ft Lt brownish gray gravel silty clayey sand some water 94 112
Material used in seal BENTONITE CHIPS Lt brown gravel sand silt water 112 122
Did any strata contain unusable water? ❑Yes El No Orangish brown gravel sand silt water 122 125
Type of water'' Depth of strata
Lt brown gravel sand silt water 125 137
Method of sealing strata off
Pump: Manufacturer's Name 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+1.2 ft.above ground surface
Static water level 11 ft.below top of well casing Date 05/15/2025
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed') X No ❑Yes 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 Time Water Level
Date of pumping test
Bailer test gpm with ft.drawdown after hrs.1
Air test 45 gpm with stem set at 135 ft.for 1 hrs Date 05i15l2025
Artesian flow gpm j
Temperature of water °F Was a chemical analysis made? ❑Yes El No Start Date 05/14/2025 Completed Date 05/15/2025
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
®Driller 0 Trtgye 0 PE-Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING
Signature `'—�-- 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 05/16/2025
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.
—
a-14(2A ,-
'TVA I L 14
, m MANAGEMENT
MK • LA 130RATOR I LS um( .
. MOM i
1515 80th St E,Tacoma.WA 98404
III= r--
lir t -COUFORM BACTERIA ANALYSIS FORM
Date Sample Collected I Time Sample I County •
Collected
0 Ao
—
. .../ I
• Type of Water System(check only one bold .
0 Group A 0 Group 8. (20ther_Pri_______
: —
Group A and Group B Systems-Provide from Water Facilities Inventory tWFI)
IDA _ . .._
System Name Ch 6r i.A.0 .r
Contact Person Aaron Richar son
Day Phone i 253) 537-7332 Cell Phone-( 254 377-0236
Email: Eve.Phone.( )
Send results.In fPnrit lull name.an*ess anc zip code}
Richardson Well Drilling
PO Box 44427
Tacoma, WA 98448
1 [
. 1 SAMPLE INFORMATION
. i Sample collected by tnamey. ry ,
ra'fr./i.4)1st__ ,
.--StTecific location where sample collected: Special instructions or comments
)64- Weil :)<IY ik Al 144/5ue
• •Selerf____
..,.1
Type of Sample( only one type of sample from types I though Sbelmv) ...
i..
1 rirlioutine Distribution Sample(A/PI 2 El Repeat Sample(AlP)
•
Chionnated.Yes No
;from Otstribution system after unsat rautile)
.• ...IX_ _ ..
Unsatisfactory routine lab number
Chlonne Residual Total Free.A
._
_ —
3.Ground Water Rule Source Sample
Unsatisfactory routine collect dale:
S ' 1 I. i /
• Chlorinated:Yes_.,„ No_
D Trvgered(Aip) Chtonne Residual Total Free
0 Assessment tAJP)
--4
4 Surface or GWI Raw Source Water Sample(Enumeration I
0 E coil 0 Fecal
5.0 Sene Cecte4 tor Information Only:
LA8 USE ONLY DRINKING WATER RESULTS LAB USE ONLY
. —
. , 0 Unsatisfactory Total Corm lifo Present and Satisfactory
L LT]E;:ol.cresent 0 E colt absent
1 —
• . I Bacterial Density Results Total Gallia-in 110Orte. E. 1100ml.
, I I Fecal Coliform _ _ _.•1001111. HPC pi nt
. . ,
•
Replacement Sample Required: 0 TNTC 0 So*too old
•
0 Sample Volume 0 Damaged Container Q.
. ' ,Ei.iTsRet:45.o 4 2,4 Lab Relerentre'pa
, .
•
R TeC eceipt rn ' LictaM„oet
IP'
Date aor.ed .*OH 5..... Lab 1.15e 0,4 AR I.83 P.
# _
i DOH Lab-§arr. .,
C"?'..•-......
• i 089, i 7 5-3 D
,...,—....,.......,7,•,..............,...y,..c..„,..,::.::.-x-,. ..7.•
I
'el,,e1:SW N01011/4.6 no 1..10 S....>J.ha 7,
aCATER 1515 Both St. E.
,t MANAGEMENT Tacoma. WA 98404
1233) ;3t-3121
Alm LABORATORIES I!:.:
NNW
Nitrate/Nitrite
Report of Analysis
Date Collected 06-02-2025 System Group Type: (circle one) A B ott,er
Water System ID Number: N/A System Name. Chris Weishaar
Lab Number/Sample Number: 089/03415 County' Mason
Sample Location At Well xxx Munson Ct, Belfair Source Number(s) (list all sources if blended or composited)
Sample Purpose: (check appropriate box) Date Received 06-03-2025
® RC-Routine/Compliance(satisfies monitoring requirements) Date Analyzed: 06-03-2025
0 C-Confirmation(confirmation of chemical result)` Date Reported. 06-12-2025
I - Investigative (does not satisfy monitoring requirements) Supervisor Initials. )7L_^
0 0 -Other(specify-does not satisfy monitoring requirements)
Sample Composition: (check appropriate box) Sample Type (check one) ® Pre-treatment/Untreated(Raw)
Ej S - Single Source 0 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.Patrick
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 -- 0.91 ' 0.5 _ 5.0 10.0 - mq/L No 300.0/HL
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. I Initials of the analyst that performed the analysis
mglL: 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 departments 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:
RICHARDSON WELL DRILLING
Aquifer Test Data
Well ID# BPS-181 Owner: Chris Weishaar
Site Address: XXX Munson Ct
Pumping Well Parcel#: 22309-76-00171
Pump On 06/02/205 12:30 Pump Off 06/02/25 14:00
Date Time Date Time
Reference Static Level 90.20 Feet Pump Size 1 HP 10 GPM
Recorded By Time Water Levels
Date Clock lapsed Tim Reading In Depth To Drawdown COMMENTS
Since Start Gpm Water
Patrick 1/0/1900 12:30 0:00 7 90.20 0.00
12:32 0:02 7 92.20 2.00
12:34 0:04 7 92.30 2.10
12:36 0:06 7 92.30 2.10
12:38 0:08 7 92.50 2.30
12:40 0:10 7 92.50 2.30
12:45 0:15 12 64.00 -26.20
12:50 0:20 16.5 95.30 5.10
12:55 0:25 16.5 95.50 5.30
13:00 0:30 16.5 95.50 5.30
13:05 0:35 16.5 95.50 5.30
13:10 0:40 16.5 95.50 , 5.30
13:15 0:45 16.5 95.50 5.30
13:20 0:50 16.5 95.50 5.30
13:25 0:55 16.5 , 95.50 5.30
13:30 1:00 16.5 f 95.50 5.30 HR
13:40 1:10 16.5 95.50 5.30
13:50 1:20 16.5 95.50 5.30
14:00 1:30 16.5 95.50 5.30
RECOVERY 0:01 1:31 92.10 1.90
0:02 1:32 91.00 0.80
0:03 1:33 90.90 0.70
0:04 1:34 90.90 0.70
0:05 1:35 90.90 0.70