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Home My WebLink AboutWAT2025-00172 - WAT Application - 10/3/2025 WAT �,(; - (.(�^t i 1.L rm. MASON COUNTY Shelton, 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: Michael Pearson Date: 6/14/2025 Mailing Address: 8371 SE Lynch Rd Shelton WA Phone: 360-349-3003 Parcel Number: 220297850040 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit �j1(1 201' - OK(Q 5 connections) 0 Division of land: N/ Individual water source (one connection), #of Parcels? SPL N/ 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 J:.EH Fonns\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 V Water well report(attached to application). Depth 87 ft. V Well capacity Test(attached to application) 11 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. V 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). 9A01"16 `4/1 Reviewer's Signatures: 10/3/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov I'age 2 of 2 I, WATER WELL REPORT DEPARTMENT OF ECOLOGY Notice of Intent No. WE59708 Unique Ecology Well ID Tag No. BRR 124 Type of Work: State of Washington Site Well Name(if more than one well): (1 Construction 0 Decommission => Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: 1D Domestic ❑Industrial ❑Municipal Property Owner Name Michael Pearson 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 8371 SE Lynch Rd Construction Type: Method: City Shelton County Mason ❑a New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool 0 Deepening 0 Other 0 Dug E Air- 0 Mud-Rotary Tax Parcel No. 22029-78-50040 Dimensions: Diameter of boring 6 in.,to 88 ft. Was a variance approved for this well? 0 Yes O No Depth of completed well 87 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 2 WWM or 0 EWM El I 0 6 in. +1 82 .25 in. l 3 I ❑ ❑ I ❑ Location(see instructions on page 2): ❑ 1 ❑ in. _ _ in. ❑ I ❑ ❑ I 0 NW '/-'Va of the SE '/;Section 29 Township 20N Range 02 ❑ I 0 in. tn. ❑ I ❑ 0 1 0❑ 0 in. in. ❑ ❑ ❑ ❑ Latitude(Example:47.12345) 47.19067 Longitude(Example:-120.12345) -122.95905 Perforations: 0 Yes O 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: l l Yes 0 No i K-Packer Depth 81 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Stainless Steel Model No. Topsoil,gravel 0 1 Diameter 5 in. Slot size .014 in.from 82 ft.to 87 ft. Diameter in. Slot size in.from ft.to ft. Silt,sand,some gravel,brown/soft 1 7 Sand,some gravel,less silt,brown/soft 7 14 Sand/Filter pack:0 Yes No Size of pack material in. Sand,silt,little water,brown/soft 14 25 Materials placed from ft.to ft. Sand,silt,gravel,brown/soft 25 34 Surface Seal: O Yes 0 No To what depth? 18 ft. Sand,silt,brown/soft 34 55 Material used in seal Bentonite Chips Coarse sand,silt,pea gravel,gray/soft,wb 55 68 Did any strata contain unusable water? ❑Yes ❑a No Clay,little sandy,gray/hard 68 80 Type of water? Depth of strata Sand,silt,some small gravel,gray/soft,wb 80 87 Method of sealing strata off Clay,gray/hard 87 88 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 16 ft.below top of well casing Date 5/15/2025 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? (3 No 0 Yes b 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. Air test 30 gpm with stem set at 86 ft.for 1 hrs. Date 5/15/2025 Artesian flow gpm Temperature of water °F Was a chemical analysis made? 0 Yes Cl No Start Date 5/15/2025 Completed Date 5/15/2025 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. O Driller 0 Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature G Cs,...,....;_- .- 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 5/16/2025 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 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST MICHAEL PEARSON 9/29/2025 8371 SOUTHEAST LYNCH RD SHELTON, WA 98584 WELL SITE ADDRESS: 8371 SOUTHEAST LYNCH RD, SHELTON Pump Make & Model: 3/4 HP Pump Set At: 70' Sounder Make & Model: Make & Model: Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 0 8' 1 12 108259 25' 2 12 108271 35' 3 12 108283 45' 4 11 108294 50' STABALIZED 5 11 108305 50' 6 12 108317 50' 7 12 108329 50' 8 11 108340 50' 9 11 108351 50' 10 11 108362 50' 15 11 108417 50' 20 11 108472 50' 25 11 108527 50' 30 11 108582 50' 35 11 108637 50' 40 11 108692 50' 45 11 108747 50' 50 55 60 RECOVERY 0 50' 1 45' 2 41 3 38' 4 32' 5 29' 6 25' 7 21' 8 18' 9 15' 10 10' 15 8' SIGNATURE- - �1A AND S PUMP AND DRILLING kjt 1` Vangi 2635 Pi VANGUARD Report of Laboratory Analysis LABORATORY Collected by: Werke and Sons Matrix 360-74S-3805 Laboratory ID: Sampling Address: Date Sampled: $371 SE Lynch Rd Date Received Shelton,WA 98584 Date Reported: Sample ID: 8371 SE Lynch Rd Analysis Result SDRL MCL Units DF Total Coliform & E. coli by SM 9223B (1DEXX) Batch ID:V250603-19 Coliform,Total Negative 1 1 MPN/100 tnL E. coli Negative 1 1 MPN/100 mL 1 Nitrate by Hach Method 10206 Batch ID:V250603-19 Nitrate (as N) ND 0.50 10.00 mg/L 1 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on