HomeMy WebLinkAboutWAT2025-00183 - WAT Application - 9/15/2025 (2) i.
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WAT2 0-5 - Or) If =)
: MASON COUNTY 415 N.6th Street
Shelton,WA 98584
J` 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 madeeutil connectioized.
2. Complete only the portion of Part 2 applying to
type of water
3. Submit completed application with any required attachments for review.
4. An a roved buildin site Ian must accom an this a lication.
Part 1: Applicant/ Parcel Identification �_ 5- 2 D Z S
Name of Applicant: fti✓�t R(t e� f car► Date: D
Mailing Address: PO, Vo' i 537 16 yYSg'+ Phone: 36D- 'f'W 7Y
Parcel Number: 3 zoo 7 - ) - 00 3/
Type of Water System Reason for Application
Building permit�+n l f �� " i I
0 Public/Community Water System(2 or more 0 Division of land:
connections)
Individual water source(one connection), #of Parcels? SPL
g Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
4 ❑ Other(explain) ❑ Replacement or Remodel(please indicate name
of water system below if applicable—no
If you have more than one residence connected of nature equired)
to this well, check the Public/Community Water g
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
Water well report attached to applicatio . Depth
79 ft.
>400
El Well capacity Test(attached to application) 15 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 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.
I' 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:
c l o Date 10/13/25
This form may be scanned and available for public view at www.masoncountywa.clov
Page 2 of 2
WATER WELL REPORT ::�-, DEPARTMENT OF Notice of Intent No. WE83383
ECOLOGY Unique Ecology Well 1D Tag No. BPF04B
Type of Work State of Washington
Site Well Name(if more than one well):
it Construction
Water Right Pennit/Certillcate No.
0 Dccorttmissien b Original instaUationNOINo.
Proposed Use: IS Domestic ❑Industrial 0 Municipal Property Owner Name Dag Parker
0 Dewatoring ❑Irrigation ❑Teat WeU Cl Otter Well Street Address Hiawatha 13lvd
ConstruedoaType: Methods City Shelton County Macon
PEI Now well 0 Alteration 0 Driven ❑Jetted ❑Cable Tool
Deepening 0 Ohm 0 Dug IS Air- ❑Mud-Rotary Tax Parcel No. 320071490031
Dimensions:Diameterofbodng B in.,tc,79 0. Was a variance approved for this well? 0 Yes El No
Depth of crimpleted weft 79 fl-
If yes,what was the variance for?
Construcdon Details: Well F
Casing Liner Diameter From To 'Mid:mess Steel PVC Welded Thread [3 TyWM Or❑EWM
® i 0 6 in. 0 79 .026 is C I 0 O 1 0 Location(see instructions on page 2):
0 I 0 in. ` in. El I 0 0 1 0 SE %.'/.ofthe NE 'A;Section 7 Township 20N Range 3W
O I 0 _in. — — r is 0 1 0 Ci 1 0 Latitude(Example:47.12345)47,238325
❑ 1 ❑ ......-_in in. ❑ I ❑ DID
Longitude(Example:-120.12345) -123.098845
Perforations: ❑Yes IS No type of perforator used Driller's Log/Comtructlon or Decommission Procedure
Size of rations_____in.by in
No.of pettbtations perforations Fosmatioa Describe by color,character,size of materinl and structure,and the kind and
Perforated from_,_.It to ft.below ground surface nature atlas materiel in each layer penetrated,with at least ono entry for each change of
Screens: 0 Yes @ No 0 K-Packer b Depth R i»fbrmntion.Use additional ebaeta if necessary.
Manufacturer's Name Material From To
Type Model N° Brown silty loam 0 3
Diameter•___ Slot size _in.from ftto- ft. MUIt6Coloradgravel,ellt,{0088 3 14
Diameter T Starke_in Bons 4 to_R Brown sandy gravel with slit binder 14 23
Saud/Filter pack:Cl Yes al No Size of pack material_is Brown medium sand,gravel,wet 23 37
Materials placed from_•__It.to ft Brown medium sandy gravel,water 37 44
Surface Seal: SO Yes ❑No Towbat depth? 18 It. Multi-colored gravel,brown coarse sand,water 44 79
Materiel used in seat. Bentonite chips
Did any strata contain unusable water? 0 Yes ID No --
Typo of water? Depth of strata
Method of seating strata off -
Pump:Manufacturer's Name •typo:
MP. Pump intake depth: ft. Designed flow rate: 8pm
Water'Levelst Land•surlhce elevation above Masa see level 223 ft.
Slick-up of top of well casing 1 ft.above ground surface
Static water level 23 ft.below top of well easing Date 10/2/23
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed?EJ No 0 Yes c by whom?
Yield gpm with ft drawdown after his.
Yield gpm with ft.drawdown after hrs.
Yield gpm with R.drawdown aner hrs.
-
Recovery data(time zero when pump is turned well
off-water level measured from we
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test
Bailor test gpm with R drawdown after_are. t
Air test 15 gpm with stout set at 80 ft,for 1 brs. Date 10/2/23
Artesian flow gpm
Temperature of water 69 °F Was a clicmioal analysis made? ❑Yes ID No Start Date 10/2/23 Completed Date 1012/23
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 aro true to my best knowledge and belief.
IS Driller 0 Trainee 0 4lPE-/p� Name Josh Koepp Drilling Company Arcadia Drilling Inc.
Signature / Address PO Box 1790
License No.2874 City,Starts,Zip Shelton,WA 98584
IF TRAINEE:Sponsor' icense No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 1012/23
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 lass can call 711 for Washington Relay Service. Persons wttha speech disability can call 877-833-6341.
I
1
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584 #BPF046
Customer: Dan Parker Well Tag#:
Depth: 79'
Phone:
Well Site Address: Hiawatha Blvd, Shelton Pump Set: 60'
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 Mln 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
r
50 Min 16.6 37.9
55 Min 16.6 39.3
1 Hr 16.6 39.6
1 1 Hr 10 Min 16.6 39.8
1 Hr 20 Min 16.6 40
Vanguard Laboratory
V f 2635 Parkmont Lane SW,Suite A
Olympia WA 98502
360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected l Time Sample I County
•
Collected Mason
07/29/2025 ° 'z'
aver
MNfi Day Yea* ___—.__�_._..............-I
Type of Water System(check only one box) —
❑Group A ❑Group B ONOther ..___
-Group A aria Group 8 Systems-Promde from Water Feol tes Inventory(WFI) 1
System Name Dan Parker _._.-.
Contact Person Arcadia Drilling,Inc
Day Phone (360 )425-3395 Cell Phone'( 1
•
Email: Eve Phone:( )
SendteStdts try iRnnt butt na!^e adcre55 and rip code Cr e- n
. ! ertataaarca7 attr.ivr.0;.^.rr AND lenr.t Jar_aaiaCn!idttg r'.
SAMPLE INFORMATION
Sample coCnced by(name):Max
Speanc location where sample collected Special Instructions or comments
li
BPFO45-241 E Hiawatha Blvd St�eir.• .}
..._
Type of Sample(select only one type of sample from types 1 through 5 below)-
1.❑Routine Distribution Sample(AP) 1 2 ❑ Repeat Sample(AIP)
;'r^:^.I d stttwHon sIsierf ter ul at r`Lnt.
Chlorinated Yes No _ Unsatisfacto y routine lab number
{ Chlorine Residua Total Free_._._..
3 Ground Water Rule Source Sample t
Unsatisfactory routine collect date.
ISI I I , l__.._... _._,..__-_
Chlorinated Yes_-.-__No_
❑Triggered(AP) Chlorin Residual:Total___.._Free_
❑Assessment(A'P) --�
4 Surface or GM Raw Source Water Sample(Enumeration) ( S I I l
10 E cot ❑Fecal :Yes Yes _ !b___
5 !)Samp+e C:ttexaac.o Information Only:LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Cottons Present and J$l Satisfactory
❑E.coe present D E col:absent
Bacterial Density Results Total Cohform._-___._........__.1100m1 E coil .._.__.- /100ml
itmf
Fecal Catorm __-_-- t HPC_---.---------....-...
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume ❑Damaged Container ❑
-.r-iao hetc+ence N�,moor �.
Oat.lie RoceM1eA •I
K. Teri.C' I Method Cc.f.k?
Z�
ut,% 1 S 2
Date Reported to IXM y tat use Orly
t ab-Sar.per
285- 73015
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