Loading...
HomeMy WebLinkAboutWAT2025-00199 - WAT Application - 9/15/2025 WAT 2_0i26 - 00iei1 I eMAI,, Is MASON COUNTY 415 N.6th 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 mad until Part water fully complletedlized. 2. Complete only the portion of Part 2 applying to the type o3. 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: e_AC,V- irk - ( Date: -::7 I.:2/ D--r- Mailing Address: 1+3a NE RI die bt 1 4 )Vd Phone. G / —7/9-9'7J Parcel Number: 2 3 33,I 4-0OO X Type of Water System Reason for Application ❑ Public/Community Water System (2 or more l Building permit - t�i-(2l )1U `, '"o I I Oh connections) 0 Division of land: Individual water source(one connection), #of Parcels? SPL Well 0 Boundary line adjustment ❑ Spring/surface water ❑ 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) 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. ❑ 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 JAEH Fonns\Drinking Water Revised 05/08/2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). — I Individual Water Well application). Depth S�S ft. • Water well report(attached to app� )• 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 tests l these tests are noted on the water well report. o if thlts from e water well eeport dole be have d.a clf the water apacity test, well report cannot be located by the applicant 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 { ❑ 1 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) Gd 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 r Adequacy for Building Permits are satisfied. Additional Growth Management requirements may app y. 36.70A RCW. 111 Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of Its Intended use for the following reason(s). cM`1_'u yM ioS(N/L Reviewer's Signatures: 10/10/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 If AirEmmemmir WATER WELL REPORT _ _ DErAHiMEN1 01 Notice of Intent No. WE59566 ECOLOGY Cheque Ecology Well ID Tag No BQC161 Type of Work: State at Wasttington Site Well Name(if more than one swill: (1Construction Cl Decommission r:) Original installation Not No. Water Right I'cmuitK'crtiftcatc No. Proposed the: ID.Domenic CI Industrial 0 Stmticipal Property Owner Name Rachel Bora Cl Dewaerirag 0 Initiation 0 Test Well 0 Other Well Street Address NE North Shore Rd _ Construction Type: Method: — El New well ❑Aletat&m O Driven 0 Jetted 0 Cable Tool City Tahuya — County Mason Li Deepening ❑Other 0 Dug O Air- ❑Mud-Rotary Tax parcel No. 32333-11-00020 Dimensions: I.)ianetee of boring 6 in..in 318 n. Was a variance approved for this well? ❑Yes 0 No Depth of completed well 318 R If yes,what was the variance l'or? Construction Derails: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread • 1 ❑ 6 m. 0 300 .25 in. (3 1 0 0 1 0 Lceation(see instructions on page 2): CR WWM or❑EWM ❑ 4.5 in. 298 318 in. Ci I it 0 i ❑ NE Yt`Y.of the NE V4;Section 33 Township 23N Range 3W • I ❑ in in. ❑ 1 ❑ ❑ 1 ❑ ❑ 1 ❑ in. in. ❑ 1, 7 CI — .__.. 1 ❑ latitude(Example:47.12345) 47.44664 N — `— ----- Longitude(Example:-12(1.12345) -123.06268 W _•_--._........_...____---. _. Perforations: 0 Yar al No Type oflerfmator used Driller's Log/Construction or Decommission Procedure No.of 1mrtoratinns Size of perforations as by--_ in Fnmtitian:Describe by color,ehvncter,size of material and structure,and the kind mut Perforated from h to R.below ground surface nature of the material in each layer penarated,with at.taxi one entry for each change of Screens: IR Yes 0 No ❑K-Packer l)epdu R. information. Ilse additional sheets if necessary Stantdaetuter'sName Cerra-lot _ _ Material Front ('o Tyle Pre-slotted Model No. Brown Gay sand and gravel __0 _ — 49 Diameter 4.5" Slot size.020 in.front 298 R,la 318 It. 49 62 Diameter Slot sire in.from _R.to_R. _Brown clay sand,small gravel Brown cemented sand,gravel 62 87 Sand/Filter puck:0 Yes 6l No Size of pack material_in. Brown clay,sand,gravel 87— 110 Materials pla+xtl from_R.to II. Gray clay 110 113 Surface Seal: Eta Yes ❑No To what depth' 18 ft Gray clay,sand,gravel 113 — 125 Material used LLt SCSI Bentonite chips Gray clay, 125 134 Did any strata contain tamable water', 0 Yes Ea No Brown clay,sand,gravel 134 185 Type of water'! lkpdu of strata tcthnd of sealing strata oft' Brown clay,sand,gravel,moist 185 229 Brown sand,gravel,moist,tight 229 294 _ Pump: Manufacturer's Name Type: Brown sand,gravel,water 294 318 II.P. Pump inuke depth: R. Designed Row role: (gum Water Levels: Land-surface elevation above mean sea level-287,n __ Stick-up of top of well casing 1_5 R.above,ground surface Static water level_254_n.below top of well casing Date 6/5/25 — Artesian preuure lbs.per squaw inch Dan _______ - -- Artesian water is contrulkd by (cap,valve,etc.) --. -._.____—.---._._..._ _ ____...............—_ . Well Tests: —_-__ \Vas a pumping teat pelt-muted"V.)No 13 Yes —' by whom ' _-.. --- -- Yield __Wpm Wpm with_R.dr +down alter_bit —. Yield g{nn+vith_It dmw,kpwu alter_hit. Yield _put with li drawdatwu alter has -.__-- -----_._._.. Recovery data(unto zero u hen pump is turned nil water keel measured from well - _, top to.rater level h Time Water 1 csel Time Water Level Time Water Level Date ulPunnping lent_-_____.._ —_— nailer test_ gpm wino_R.drawdown after_tits Air rest 1. ppm with stun set at 280 It litr 1.5 hit • Date 6/5/25 ._._ Artesian limos_gtau ' Temperature of water 50 "F Was a chemical analysis made? 0 Yes ED No Start Date 6/3/25 Completed Date 8/5/25 WELL-CONSTRI'CFION CERTIFICATION: I constructed and/ut accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above arc true to my best knowledge and belief 0 Driller to trainee LI PE-Print N'nte James Johnson Drilling Company Arcadia Drilling Inc. Signature r,,'k,......, %: .1-t. ' ' • - Address PO Box 1790 License No. 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2874 /," Contractor's Sp o nsor's Signature ,F,---���.-.- 74c, Registration No.ARCADDI098K1 Date 6/5/25 ECY 050-1-20(Rev 09/18) lfyou need this document in an alternate format.please call the u-mer Resources Pmgrant ar 360407-6872. Persons with hearing loss can call 711 fur Il'ashington Reloy Service. Persons with a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.Q. Box 1790 Shelton,WA.98684 Well Tag#: gQC161 Customer: Rachel Borg Site Address: NE North Shore Rd,Tahuya Depth:Static: 318'8'9' Date of Test: 6119126 pum• Set: 290' RECOVERY TIME GPM LEVEL TIME LEVEL 1 Min 6 266.8 2 Min 6 267 1 Min 267.6 3 Min 6 267.2 2 Min 267.1 3 Min 267 267.3 4 Min 6 5 Min 6 267.36 4 Min 266.8 5 Min 266.8 267.4 6 Min 6 7 Min 6 267.46 6 Min 266.7 7 Min 266.6 267.6 8 Min 6 9 Min 6 267.6 8 Min 266.E Min 266.E 10 Min 12.6 267.6 9 9 Min 266.6 15 Min 12.6 269.7 20 Min 12.6 269.7 25 Min 12.6 269.8 30 Min 12.6 269.9 35 Min 12.6 260 40 Min 12.6 260.06 45 Min 12.6 260.1 50 Min 12.6 260.1 55 Min 12.6 260.1 1 Hr 12.6 260.1 1 Hr 10 Min 12.6 260.1 Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 vg1217,Alga 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 06/19/2025 3 4 5 m PIA RhnA pay Yex Type of Water System(check only one box) 0 Group A 0 Group 8 0 Other, Group A and Group 8 Systems-Provide from Water Facilities Inventory(WFI): NM ---- - . ---- — - __-_.- SyslemName: Rachel Borg Contact Person:Arcadia Drilling,Inc _^ I Day Phone:(360 )428-3395 l Cell Phone:( ) Emat: Eve.Phone:( ) Send resits to:(Print lull name,address and Spode or e•mait) arleta@arcad1adrllina.Com AND jennigercadiadrnhn9 corn I1 t t SAMPLE.INFORMATION ----- Sample collected by(name):Shad _ +- 1 Specific location where sample collected: Spacial instructions or comments: BaC161-NE North Shore Rd,Tahuya I Type of Sample(select only one type of sample from types 1 Uvough 5 below) - i 1.❑Routine Distribution Sample(AfP) 2.CIRepeat Sample(MP) (hem distribution system alter unsat routine) Chlorinated:Yes.—__.No. ___1 Unsatisfactory routine lab number: Chlorine Residual:Toia free_.-- ____ _... _._.__--- r 3.Ground Water Rule Source Sample Unsatisfactory rouGnQ collect dale. � Sl l l _ l- f Chlorinated:Yes No 1 El Triggered(AJP) Chorine Residual:Total Free__. o Assessment(A/P) i4. Surface or GWl Raw Source Water Sample(EntimaraliOn) I S I I I 0 E.col 0 Fecal Fdered Yes__—.n'---... 5.lip Samna Cosseted for Information Onty: — LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coriform Present and 161 Satisfactory 0 F_.cofr present 0 E.cor absent Bacterial Density Results:Total Colifonn�. It00nrl. E.coli _.- 1100m1. + FocalCdtorm _ 1100m1. HPC __._11 ml li Replacement Sample Required: 0 TNTC 0 Senple too old ❑ Sample Volume 0 Damaged Container 0 _ _ Date/Ti R tab Reteren Number ©tn ra 1kg'.00 \1Th LQ20-ly Recelpt Tamp C': Method Code: SM9223B r 0 --- Date Reported to DOt t 06/21/25 tab Use Only: DOH LeGSamplee 285-62014 eOHrao gJI.11rltlkm.0 M1OwrAeUv+rmaer e.e Db Ndlw 01* ` b aiti tratYmwr+9