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HomeMy WebLinkAboutWAT2025-00162 - WAT Application - 8/1/2025 WAT 2025-00162 ak, MASON COUNTY 415N.6'hStreet 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: Ian & Kate Parnell Date: 8/1/25 Mailing Address: 4780 E McReavy Rd Phone: 360-581-1947 Parcel Number: 421355000047 Type of Water System Reason for Application 0 Public/Community Water System (2 or more Ja' Building permit connections) 0 Division of land: fd Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water 0 Other (explain) 0 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) 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. 0 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:1EH Fonns\Drinking Water Revised 05/08i2024 Page 1 of 2 7 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well % Water well report(attached to application). Depth _158__. ft. >400 ,e( Well capacity Test (attached to application) 20 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 cf draw-down and recovery data, must be performed by a licensed contractor. Ja' Satisfactory bacteriological test within last year (attach to application). Individual Spring/Surface Water 0 WDOE permit (attach to application) ❑ Method of disinfection El 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). 'R0 Reviewer's Signatures: 9/15/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.qov �_� „r2 taw WATER WELL REPORT r_-,.•;: _ A DEPARTMENT OF Notice of Intent No. WE45295 ECOLOGY Unique Ecology Well ID Tag No. BNX161 Type of Work: MO State of Washington Q Construction Site Well Name(if more than one well): O Decommission . Original installatioo NOI No. Water Right Pemtit/Certificate No. Proposed Use: CI Domestic ❑industrial 0 Municipal Property Owner Name Michael&Theodora Millelle(PWN Investments) 0 Dhsvatcring 0 Irrigation El Test 1VelI 0 Other Well Street Address Clear Lake(Lot 20) Construction Type: Method: l4 New weil ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug ©Air- 0 Mud-Rotary Tax Parcel No. 42135-50-00047 llinterrsions: Diameter of boring 6 in,to 158 ft. Was a variance approved for this well? ❑Yes El No Depth of completed well 158 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread Q I ❑ 6 in. 0 154 0.25 in. Ly I 0 O I 0 Location(see instructions on page 2): [WWA1 or D EWM ❑ 1 it in. _ in. ❑ I 0 0 I 0 NW %-V,of the SW Y,;Section 35 Township 21 N Range 4W ❑ 1 ❑ in. _ in. ❑ I ❑ DID ❑ I ❑ in. _ _in. ❑ 1 ❑ ❑ I ❑ Latitude(Example:47.12345)47.264399 L Longitude(Example:-120.12345) -123.161112 0r:s Perforations: U Yes NI No Type of perforator used 0 No.of perforations_ Sizef perforations_in.by—in Driller's Log/Construction or Decommission Procedure r_ o per onsFormation:Describe by color,character,size of material and stntcture,and the kind and i Perforated Rom—ft.to ft below ground surface nature of the material in each layer penetrated,with at least one entry for each change of 3 Screens: 0 Yes 0 No W K-Packer b Depth 152 ft_ information. Use additional sheets if necessary. to Manufacturer's Name Alloy Machine Works Material From To } Typo StainiessSlotted Model No. Brown sit Diameter 5. Slots from size.018 in_ 153 ft.to 158 R. ty sand&gravel,loose 0 6 o Diameter Slot size in.from it.to ft. Multicolored gravel,loose 6 11 o Brown silty sand&gravel 11 22 Sand/Fiiterpack:❑Yes P1 No Size of pack material in. Brown silty sand&gravel with clay binder 22 35 O Materials placed from ft.to ft. E Gray silty sand&gravel with day binder 35 42 o Surface Seal: 9 Yes ❑No To what depth? 19 ft Brown silty sand&gravel 42 107 4- Material used in seal Bentonite Chips - Small to medium multtcolored gravel,loose 107 136 Did any strata contain unusable water? ❑Yes FINo • Type of water? Depth of strata Multicolored gravel,medium brown sand, 136 nizi Method of scaling strata off loose.Water 158 a Pump:Manufacturer's Name Type: ` 0 A.P. Pump intake depth:—ft. Designed flow rota: gpm 0 - a Water Levels: Land-surface elevation above mean sea level 370 ft. N Stick-up of top of well casing I ft.above ground surface .1 Static water level 112 ft.below top of well casing Date 9/10/2021 4. Artesian pressure lbs.per square inch Dale a Artesian water is controlled by (cap,valve,eta.) 0 r- s- O Well Tests: 3 Was a pumping test performed? E7 No ❑Yes i=> by whom? I- Yield gpm with. IL drawdown after hrs. Z Yield gpm with_ ft.drawdown after hrs. T . ^•r` i`-'r"'I` !('" Yield gpm with R.drawdor+m after bra. ".'. " (_ r V _ } IA N Recovery data(limo-zero usben pump is turned off-scaler level measured from well .10 top to water level) i", , ,. r " l r, 1 Time Water Level Time Water Level Time Water Level 1R... .. .. i l f.t O - --- - ..._.-5 rr,' Seit: .,1F111• r;i — 4— Date of pumping test - O Bailer test ppm with ft.drawdown after_hrs.} 4- Air test 20 gpm with stem set at 140 ft.for 1 hrs. Data 9/10/2021 a EN Artesian flow ppm —....... ......_--- -' Temperature of water 49 °F Was a chemical analysis made? ❑Yes I No Start Date 9/10/2021 Completed Date 9/10/2021 EL • WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well a construction standards.Materials used and the information reported above are true to my best knowledge and belief. iv s CI Driller❑Trainee 0 PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature : ,-` Address PO Box 1790 l License No. 2874 i t .!,7' City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No . Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 9/10/2021 ECY 050-1-20(Rev 09/18) If you need this document in an alternate font at,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 call877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Craig Gregory Well Tag#: BNX161 Phone: 360-280-0024 Depth: 158' Well Site Address: W Clear Lake Dr, Shelton Pump Set: 140' Date of Test: 9/15/2021 Static: 111.9 TIME GPM LEVEL RECOVERY 1 Min 5 112.5 TIME LEVEL 2 Min 112.8 1 Min 112 3 Min 112.8 2 Min 111.9 4 Min 113 3 Min 5 Min 6.5 113.1 4 Min 6 Min 113.1 5 Min 7 Min 113.1 6 Min 8 Min 113.1 7 Min 9 Min 113.1 8 Min 10 Min 10 113.1 9 Min 15 Min 113.5 10 Min 20 Min 12 113.6 11 Min 25 Min 113.8 12 Min 30 Min 113.9 13 Min 35 Min 113.9 14 Min 40 Min 113.9 15 Min 45 Min 113.9 16 Min 50 Min 113.9 17 Min 55 Min 113.9 18 Min 1 Hr 113.9 19 Mn 1 Hr 10 Min 20 Min 1 Hr 20 Min 21 Min 1 Hr 30 Min 22 Min 1 Hr 40 Min 23 Min 1 Hr 50 Min 24 Min 2 Hr 25 Min 2 Hr 10 Min 26 Min 2 Hr 20 Min 27 Min 2 Hr 30 Min 28 Min 2 Hr 40 Min 29 Min 2 Hr 50 Min 30 Min 3 Hr 3 Hr 10 Min 3 Hr 20 Min 3 Hr 30 Min 3 Hr 40 Min 3 Hr 50 Min 4 Hr Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 WR.F,sB 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 07/25/2025 0 o AM Month Day Yea PM Type of Water System(check only one box) ❑Group A ❑Group B ®other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Ian & Kate Parnell 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-mai) adeta@arcadiadrilling.com AND jenn@arcadiadnllog corn SAMPLE INFORMATION Sample collected by(name):Shad Specific location where sample collected Special instructions or comments BNX161-790W Clear Lake Dr,Shelton Counts please Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2.❑ Repeat Sample(A/P) Chlorinated:Yes No (from distribution system after unsat routine) Unsatisfactory routine lab number Chlorine Residual:Total Free_ _ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S I / I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) S ElE.coil 0 Fecal Fat...a Y,__ w; _ 5.4 Sampe Collected tor Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory ❑E.coli present ❑E.cok absent Bacterial Density Results:Total Coliform <1.0 I100m1. E.coh <1.0 mood. Fecal Conform I100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container 0 DaterTime Received Reference Number 07/25/25 j7tC2 7 c- ? Receipt Temp C° Method Code: 5.4 SM9223B Date Reported to DOH Lab Use Only. 07/29/25 DOH Lab.Sample= 285-72526 DON pen,0331419tcL Era Obi?).X fo,Need ifts rAtate°an nM alernolve brmn(gll 8005250127I'taxi Yap1Pit) Ns end Drier pilbedl fs aratoble al arm Con Y FNAMILnQMbr