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HomeMy WebLinkAboutWAT2025-00183 - WAT Application - 9/15/2025 WAT 20 - • s' MASON COUNTY 415 N.6th Street Shelton,WA 98584 L ,: Shelton:360-427-9670,Ext.400 .. -.- :V 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: �i►' PA R l{e2 Date: _G`— / Z D L 6 iiitas'✓ WA Mailing Address: PO, 670,< 1$37 cr(Ceze Phone: 360 'leo- 7 0 Parcel Number: 3 2007 - - `700 3/ Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 1X1 Building permit l d 242.5 --O I I I Cs connections) ❑ Division of land: X Individual water source(one connection), #of Parcels? SPL ffi Well ❑ Boundary line adjustment ❑ Spring/surface water El 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) ❑ 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:\EH Forms\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 X1 Water well report attached to applicatio '. Depth 79 ft. IN Well capacity Test(attached to application) 15 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. IE Satisfactory bacteriological test within last year(attach to application). 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) kl 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. Li Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). IRAttr/v\O11-l4 Reviewer's Signatures: Environ. Health: Date 10/13/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of WATER WELL REPORT ' DEPARTMENT OF Notice of Intent No. 1/VE633fi3 111,211 ECOLOGY Unique Ecology Wall IDTagNo. BPF046 Type of Work State of Washington 0 C• onstructionSite Well Name(if more than one well): ❑ Dcconuoissiou r=:, Original inataltalionNOlNo. Water Right Pennn/CertificateNo. Proposed Use ©Domestic 0 Industrial 0 Municipal Property Owner Name Dail Parker _ 0 Dewstericg 0 Isrigatlon 0 Test Wall 0 Other _ _ Well Street Address Hiawatha Blvd CorastructioaTypo: bleared: P.i Now well ❑Alteration CIDriven Cl Jetted ❑Cable Too! City Shelton County Mason ❑Deepening ❑Other ❑Dug G]Air- 0 Mud-Rotary Tax Parcel No, 320071490031 Dimensions:Diameterofboriog 6 is,to 79 R Was a variance approved for this well? 0 Yes Cl No Depth ofcotepleted well 79 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread RI I 0 6 io. 0 79 -.026 in. DI I. ❑ © I 0 Location(see instructions on page 2): i3 WWM or Cl EWM ❑ I ❑ in- in ❑ I ❑ ❑ I ❑ SE %44ofthte NE 'A;Section 7 Township 20N Range-3W ❑ 1 ❑ in. _ in. ❑ I ❑ ❑ I ❑ ❑ .l 0 ___in. , in. Cl 1 0 0 I ❑ Latitude(Example:47.12345)47,238325 Longitude(Example:-120.12345) -123.098846 Perforations: 0 Yes lid No Typo ofperforator used , — No.of perforations _ S zeofperforation.s is by_in Drillers Log/Construction or Decommission Procedure from lb to P.below ground surface Formation_Describe by color,character,size of material and stream*,and the kind and Perforated nature of the material in each layer penetrated,with at least one natty for each change of Screens: Cl Yes 52 No 0 K•Packer w=> Depth_It. information. Uso additional sheets if accessary. Manufacturers Name Material From To Type Model No. - Diameter Slot sizoin.from R to fl. Brown silty loam 0 3 Diameter _ Slotsizo is from -ft.to ft. MUIB-colored gravel,slit,loose 3 14 Saod/hiitarpack;0 Yu fsl No Size ofpack materialm Brown sandy gravel with slit binder 14 23 Material placed Gom ft.to ft iv- Brown medium sand,gravel,wet 23 37 Brown medium sandy gravel,water 37 44 Surface Seal: 61 Yes Cl No To what depth? 18 ft. Multi-colored gravel,brown coarse sandwater 44 79 Material used in scat 1Bentonitechips Did any strata contain unusable water? ❑Yes Fill No - - Typo of water? Depth of strata - Method of sealing strata off Pump: Manufacturer's Name Typo: 1 H.P. Pump intake depth: ft. Desiguod flow into: gpm --- Water Levels: Land-surface elevation above mean sea loyal 223 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 23_ft.below top of wall easing Date 1012/23` - ---- -— Anosian presence lbs.per square inch Dato _ - Artesian water is controlled by_ (cap,valve,etc.) Well Tests: Was apumping test performed? PI No ❑Yes b by whom? Yield gum ith ft dmwdown after lus. Yield,—gpm with,it.tkawdown after bra. Yield gpm with ft.drawdown after hrs. Recovery data(time-zero when pump is turned off-water level measured Gout well top to water level) - Time Water Level Time Water Level Time Water Level -- Date of pumping test Bailor test gpm with ftdrawdown after tiro . Air toss 15 gpm with stem set at 60 ft.for 1 hrs. Data 10/2/23 Artesian flow gpm Temperature of water 50°F Was a chemical analysis made? 0 Yes RI No • Start Date 10/2/23 Completed Date 10/2/23 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance wills all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. El Driller 0 Trainee Q PE-Pin Name Josh Koep Drilling Company Arcadia Drilling Inc. 3 Signature / Address PO Box 1790 License No.2874 Cily,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor'GL'rcense No. Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Date 10/2123 ECY 050-1-20(Rev 09118) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing lass can call 711 far Washington.Relay Service. Persons svitka speech disability can call877-833.6341. - di Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Dan Parker Well Tag#: #BPF046 Phone: Depth: 79' Well Site Address: Hiawatha Blvd,Shelton Pump Set: 60' 1 Date of Test: 10/5/2023 Static: 23' TIME GPM LEVEL RECOVERY 1 Min 3.1 27.6 TIME LEVEL 2 Min 3.1 27.8 1 Min 32 3 Min 3.1 27.9 2 Min 20 4 Min 3.1 27.9 3 Min 27.9 5 Min 5.5 27.9 4 Min 27.5 6 Min 5.5 28.7 5 Min 27 7 Min 5.5 28.9 8 Min 5.5 29 9 Min 5.5 29 10 Min 8.3 29 15 Min 8.3 31.5 20 Min 11.5 31.5 25 Min 11.5 33.7 30 Min 14.2 34.1 35 Min 14.2 35.9 40 Min 15.7 36 45 Min 15.7 _ 37.5 50 Min 16.6 37.9 55 Min 16.6 39.3 i 1 Hr 16.6 39.6 1 Hr 10 Min 16.6 39.8 1 Hr 20 Min 16.6 40 I Vanguard Laboratory V 2635 Parkmont Lane SW,Suite A Olympia \VA 98502 yaxaaa:!--1 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample — County Collected 07/29/2025 ❑A, Mason Mill Day yea _..___ _—_E.'', • Type of Water System(check only one box) 0 Group A 0 Group B 0 Other Group A and Group B Systems-Provide from Plater Facilities Inventory(WFI) 'DC System Name Dan Parker • Contact Person Arcadia Drilling.Inc Day Phone:(360 !426.3395 Celt Phone ( ) Email: Eve Phone ( ) Send resets 5(c--.s_u name aldress am zlp ccCv:r e--a ane:a�arua=.a,•-,-,nucci ANDler.maarcauuc•hrg::,^. • SAMPLE INFORMATION Sample collected by(name)-Max Specific location where sample collected I Special instructions or comments BPF045-241 E Hiawatha Blvd Shettc-.II Type of Sample(seed on:y one type of sample from types 1 through 5 below) 1 ❑Routine Distribution Sample(MP) 2 ❑ Repeat Sample(AP) Chlorinated Yes No (from dslributOn system after unsat rOu6rcj Unsatisfactory roubne lab number ChlorineRes:dual Total._ Free 3 Ground Water Rule Source Sample i Unsatisfactory routine collect date S I 1 I Chlorinated Yes No ❑Triggered(.4Pi Chlorine Residual Total Free ❑Assessment (.A-P) 4 Surface or GWI Raw Source Water Sample(Enumeration) SI I I • ❑E coh ❑Fecal -_-. r.-- 5 0 Sampe Cci,ectec for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Cohform Present and Xl Satisfactory ❑E cola present ❑E cod absent Bacterial Density Results Total Coldonn_ I100m1 E cola 1100m1 Fecal Co'fc,rn f 100m1 HPC !I mi Replacement Sample Required: 0 TNTC 0 Sample too old ! ❑ Sample Volume 0 Damaged Container 0 Da:rr ire R-carvad lax Rcicrvece Nurnbar \(031.A v2FDb"l�b- 1 R apt Tern C• Nei ai Code y,qb S 22 '?) Dale Reported to DO( Lab Use 0rry • DON Lab-Sampe= -..-- 285- 73015 s-mrt•;reer.r:-.,r; .ro.-tea t.crate-r•eeer.rnbrra.aysxsysCIF(Teri.cm.:•, Th.rt:ne,es.a:afs vs.e+m...r am%sr a.)e.ry1e,0410