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HomeMy WebLinkAboutWAT2025-00193 - WAT Application - 10/9/2025 wAT -202, - 00 i _ MASON COUNTY 415N.6"'Street Shelton.WA 98584 al 4 Shelton:360-427 9670,Ext.400 Public Health & Human Services Belfnir: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: -6:_,-�'-( k�\6'f �� 1�-`C{-r-!' S Date: 6- -- �' l' 2- Mailing Address: 0101 %maw" IC ppJ Phone: 3Lo ?Lt0 SSA Parcel Number: ,5 Z 0 U ' r1--o oo 8 L) - Type of Water System Reason for Application ,��_ Gil `D 0 Public/Community Water System(2 or more 69 Building permit-filet 26 connections) 0 Division of land: EN Individual water source(one connection), #of Parcels? SPL MI Well 0 Boundary line adjustment 0 Spring/surface water ❑ Other(explain) ❑ 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 I\GiI formsv Drinking Water Re‘iscd 05!O8'202: Pace I of 2 immiimmor ..—_... Group B Water Systems -- - — U Satisfactory bacteriological test within last year(attach to application). Individual Water Well rj IZ3 Water well report(attached to application). Depth V ft. ® Well capacity Test(attached to application) ( - 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. 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's Signatures: Environ. Health: Date 10/9/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 1 WATER WELL REPORT ic._`_ ' '1 DEPARTMENT OF Notice of Intent No. WE47054 ECOLOGY Unique Ecology Well ID Tag No. BNX204 Type of Work: State of Washington Site Well Name(if more than one well): C] Construction r ❑ Decommission r==> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: IN Domestic ❑Industrial 0 Municipal Property Owner Name Chris Keller 0 Dowatoring 0 Irrigation 0 Test Well 0 Other Well Street Address 15007 W Shelton Matlock Rd Construction Type: Method: City Shelton County Mason J Now well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool ❑Deepening 0 Other 0 Dug Q Air- 0 Mud-Rotary Tax Parcel No. 62007-75-00080 Dimensions: Diameter of boring 6 in,to 99 R. Was a variance approved for this well? 0 Yes O No Depth of completed well 98 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 13 WPIM or ID EWM Q I 0 g in o ps .025 in. alp sin Location(see instructions on page 2): p I ❑ in. in. ❑ 1 ❑ DID SW '/-'//of the NW %;Section 7 Township 20N Range 6W ❑ I ❑ in. J in. ❑ I ❑ DID❑ I ID in. in ❑ ❑ ❑ I ❑ Latitude(Example:47.12345) 47.228360 -- _ Longitude(Example:-120.12345) -123.364376 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 ❑K-Packer b De th ft. information. Use additional sheets if necessary. Screens: CI Yes �No V Manufacturer's Name Material From To Type Model No. Brown silty sand and gravel,cobbles 0 6 Diameter Slot size_in.from ft.to ft. Brown siltbound sand and gravel 6 12 Diameter Slot size in.from ft.to_ft. -- 12 24 Gray silty sand and gravel,tight Sand/Filter pack:LJ Yes E6 No Sizo of pack material in. Multicolored sharp gravel,brown fine sand, 24 Materials placed from ft.to, ft. slit,loose --- 77 Surface Seal: Ill Yes 0 No To what depth? 19 ft. Multicolored gravel,coarse brown sand, 77 Material used in seal Bentonite Chips loose,wet 81 Did any strata contain unusable water? ❑Yes No Multicolored gravel,coarse brown sand, 81 Type of water? Depth of strata 98 loose,water Method of sealing strata off - _ Brown silty sand and gravel,less water 98 99 Pump: Manufacturer's Name Ti'Pe: H.P._ Pump intake depth: ft. Designed flow rate: Pm Water Levels: Land-surface elevation above mean sea level 450 g, Stick-up of top of well casing 1 ft.above ground surface Static water level_65 ft.below top of well casing Date 3/7/22 _ Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? 7 No ❑Yes by whom? Yield gpm with ft.drawdown after_hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with ft.drawdown after T hrs. Recovery data(lime_zero when pump is turned on'—water level measured from well _ _ __.. _ — top to water level) Tiers Water Level Time Water Level Time Water Level _______ — - -- i Date of pumping test Bailor test gpm with ft.drawdown after hrs. Air test 12__gpm with stem set at 80 ft.for 1 hrs. Date 3/7/22 Artesian flow gpm _. Temperature of water_°F Was a chemical analysis made? 0 Yes i7 No Start Date 3/7/22 Completed Date 3/7122 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. 0 Driller❑Trainee 0 PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. , Signature /�� Address PO Box I License No.2874 City,State,Zip Shelton,WA 98584 1 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature _ Registration No.ARCADDI098K1 Date 3/7/22 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. 1 Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. i 1 Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Chris Keller Well Tag#: BNX204 Site Address: 811 W Winchester Way, Shelton Depth: 99' Date of Test: 10/8/2025 Static: 78' Pump Set: 60' TIME GPM LEVEL RECOVERY 1 Min 12 78.8 TIME LEVEL 2 Min 12 78.9 1 Min 78 3 Min 12 79 2 Min 78 4 Min 12 79.1 3 Min 78 5 Min 12 79 4 Min 78 6 Min 12 79 5 Min 78 7 Min 12 79 6 Min 78 8 Min 12 79 7 Min 78 9 Min 12 79 8 Min 78 10 Min 12 79 9 Min 78 15 Min 12 79 10 Min 78 20 Min 12 79 11 Min 78 25 Min 12 79 12 Min 78 30 Min 12 79 13 Min 78 35 Min 12 79 14 Min 78 40 Min 12 79 15 Min 78 45 Min 12 79 16 Min 78 50 Min 12 79 17 Min 78 55 Min 12 79 18 Min 78 1 Hr 12 79 19 Min 78 1 Hr 10 Min 12 79 20 Min 78 21 Min 78 !Total Gallons Pumped = 840 1 22 Min 78 23 Min 78 24 Min 78 25 Min 78 26 Min 78 27 Min 78 al 28 Min 78 29 Min 78 30 Min 78 • ._'s s�r �'•,.r�yrar.E ft.7t cs,.� •4r,;, -ayt; .µ•, _=4C�,;4:.. . • Thurston County Environmental Health 412 LIlly Rd NE 0 Olympia,WA 98506 l5 36t7 867-Z631 .._ THURSTON COUNTY ®s®ee COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Day Year 5 oZo/� Collected�J • Month :1 O PM Type of Water System(chock only one box) 0 Private Househo ❑Group A ❑Group B 0'Other t / Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# • -- — — System Name: • Contact Person:'idb) k.4II er • Day Phone:(Ago) d 6 3 V° 1 Cell Phone:( ) E-mail: /J keJk4rZ Q (( LdoGutl P bDRe:( ) Send results lo:(�dnt full name,address and zip code or email address) SAMPLE INFORMATION ' Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: • Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat,routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total Free_ Chlorinated:Yes__._.._..No`._.._ 3,Raw Water Source Sample Chlorine Residual:Total_ —_Free ❑E.coll—GWR(A/P) ❑Fecal—Surfer"Gwi,springs(numeration) Unsatisfactory routine lob number, Filtered:Yos�No _ { ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other ) SI 1 }( 4.❑Sample Collected for Information Only Investigative Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coilform Present and Satisfactory ❑E.col/present ❑E.collabsent o liform Replacement Sample Required: 0 Sample too old(>30 hours) 0 TNTC ❑ l Bacterial Density Results:Total Collform /100m1. E.coll 1100m1. • Fecal Coliform 1100m1 Enterococci /100 ml. • Method Code:$ M 9223E ❑SM 9222D Date and Time Received: p SM 9215E ❑Enterolert® )s.ZazS O"l Date end Time Analyzed: .T 7 co Date Reported:S 1,MS'M.k Sampio Number(DOH number plus fire digits) Lab Qs Lab Use Only@ trrN+NAy �+ �`,1.r 0 8 0 '2_Cl 5, 6'zC DOH ' a �3�rensed t J ^ '