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Home My WebLink AboutWAT2025-00207 - WAT Application - 11/3/2025 WAT 2025-Q0207 CMASON COUNTY ol COMMUNITY SERVICES �, Rukling,Planning Environmental Hcalth,Community Health 1j y J.Hl �'_i • 415 N 6"'Street, Bldg 8. Shelton WA 98584, Shelton: (360)427-9670 ext 400 ❖ Beflair: (360)275-4467 ext 400 •: Elma: (360)482-5269 ext 400 FAX(360)427-7787 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 Paul & Darla Fiedler September 28, 2025 Name on Applicant: Date: _— Mailing Address: 5930 NE 65th CT Vancouver WA 9866 phone: (253)229-0011 Paul's celUtext Parcel Number: 321055100007 Type of Water System Reason for Application . gl Public/Community Water System (2 or more RI Building permit connections) 0 Division of land: 0 Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment - • ❑ Spring/surface water 0 Other(explain) 0 Other(explain) 0 Replacement or Remodel(please indicate name it 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: _210 and 220 E Arellem Rd 2-party well Water Facility Inventory(WA) Number: none (write"none` for two-party) .l I am the manager of this water system. The water system has been approved for twoservices. There are presently one connection(s) in use. This will be the second connection. ❑ I am the manager of this system. This connection will be to upgrade or change the use of art 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 nd local regulation. Signature of Water System Manager �� g Y Date_September 28, 2025_ ?'A v L. r'cEzt ,F a, This form may be scanned and available for public view at www.co.mason.wa.us. I Fit Forms`Drinking\biter Revised l/'-jnOIR 41111.11.1 Individual Water Well ® Water well report(attached to application). Depth 338 ft. ® Well capacity Test(attached to application) 12 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. El Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA hftp://gis.co.mason.wa.us!planninq 14_15 16_22_ Water use or limitation recorded..................... N/A Yes Well Drilled . ................................. Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) O Method of disinfection ❑ I have reason to believe that this water source can provide at least 800 gallons per day; andlor 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s)- Reviewer's Signatures: c9Irvyyr\i6 11/3/2025 Environ. Health: Date CSD Director: Date oft x , DEPARTMENT OF Notice ofIntentNo. WE45549 WATER WELL REPORT1i ECOLOGY Unique f Intent Well ID Tag No. BMS096 Type of Work: State of Washington Site Well Name(if more than one well): ❑ Decommission O De9 ° � Original installation x01 No. Water Right Permit/Certificate No. Pad OW Ti Dotnestic :laduutrial 0 Municipal PropeRy Owner Name ❑Dewatering p irrigation ❑Tut Well ❑Other Well Street Address 210 E Ar9btun Rd _ Construction Typo: Method:Pl City Union Courtly Mason New well 0 Alteration 0 Driven 0 lend 0 Cable Tool ❑Deepening O Other O Dug 9 Air. 0 Mud-Rotary Tax Parcel No 32105-51-00007 Dimensions: Diameter ofboeing 6 in.,to 340 R Was a variance approved for this well? 0 Yes 1)No Depth of completed well 338 fl If yes,what was the variance for? Construction Details: Wall - Cuing Liner Diameter r m Thickness Steel PVC Welded Thread Or WyVly(�0 EWM l3 1 ❑ n. 338 0.25 is 3 I 0 1E 1 ❑ Location(see instructions on page 2): ❑ I ❑ in in ❑ I ❑ O 1 O NE V.-'/.of the SW V.:Section 5 Township 21 N Range 3W ❑ i O in itt. O I O 010 Latitude(Example:47.12345) 47.336791 N Longitude(Example--120.12345) ❑ I ❑ in. in ❑ I ❑ ❑ i ❑ 123.091053 w Perforatiossi 0 Yes O No Type of perforator used• Driller's Log/Cosftr action or Desommissioa Procedure Sim or m by--- Feematioo:Describe by color,character,size of material tad mnrcnrc.sad tie kind and Ne of perforations perform__ Perforated from_ft.to ILbelow ground surface name of the raMerial Much layer penetrated,with at Teat ono entry for each slrastye of infmmatioa. Uaa oddities',Beets if necessity. Sereess: ❑Yes Q No 0 K-Packer b Depth_ft. From To Material user's Name 0 Type Model No. Brown fine to medium sandy gravel,silly. p _, Slot size__in.bete R to A tigrt dry Disorder slot size T_;A it to fl 53 Multih, 53colored medium sand,sharp gravel, i Sand/Flter pack:0 Yes El No Size of pack material. . light.dry 1 6 ��pad from_ft. in.to_ft. Brown fine to coarse sandy gravel,loose,dry 86 08 Sharp gravel multi colored,tight dry 108 231 Surface Sad: Ill Yes CI No To what depth? 20 R 231 288 Material weed in seal Bentonite chic's Brown fine sandy gravel,tight dry 288 Did any scan coattail:,unusable water? 0 Yes 0 No Brown medium to coarse S. • •ravel, Typo of wuet Depth of strata — 294 loose,wet 294 299 Method of seating seats off Brown fine sandy chocolate peat,stiff,dry Type• Brown gravelly fine sand,loose,water silt 299 301 Pump: lrlaoufacturv'sNamc__H.P._ Pump intake depth- It Designed flow rate:—pm Brown medium sandy gravel,tight,wet 301 315 315 316 Wafts I.asels: Land-surface elevat mean ion above as Gray day.stiff,dry level 54fi fl silt 318 Stick-up of top of well casing 1 E.above ground surface Black fine to medium sandy gravel,gray31S Static water level 286 ft.below top of well casing Date 11/11/21 bound,dry Artesian pressure_lbs.per square inch Da2e Brown medium sandy gravel,tight,dry 3i9 328 Artesian water is controlled by _.(cap,valve,cat:.) 328 335 Gray day,stilt,dry Well Tests: Brown medium to coarse sandy gravel, 335 339 Wass pumping test performed? El No El Yea by whom? loose,Water Yield gpmwith._-ft dnwdown after hrs. 339 340 Yield tilsm with ft drawdown after tars_ Brown sharp_coarse sa • r ravel,ti•ht,d Yield gpm with el drawelowu aft his Recovery data(time-zero when pump is tumid off-water level measured from well _. cop to wept Waterat) Water Level Time Water Level Time Level Tux - Due of pumping teat —' Better test gpm with_fl draawdown after hrs.1 Air test 20 gpm with stem se at 325 ft for 1 hrs. Date 11/11/21 Artesian flow Slat Date 11/11/21 Temperance of water 51 °F Was a chemical analysis made? CI Yes IC No Start Date 11/9/21 Completed WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility fix construdion of hi well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge 1. Si Driller O Trainee 0 PE% „u R rev D Phythian Drilling Company Arcadia Drilling inc. %// Address PO Box 1790 Signature City,State,Zip Shelton,WA 98584 r Liccrllte)!io.2053 License No. Contractor's IF TRAINEE:Sponsor's11/11/21 Registration No ARCADDI098K1 Date 5ponsor's Signature ECY 050-1-2 09/18) If ynu need this document in an alternate format,please call the Water Resources Program at 360-407.6872. Printed F ro less con calf 711 for Washington Relay Service Persons with a speech disability can call 877-833-6341. 1 A i GO.t -- Plinted fron'1 Mason County DMS ;..,a Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Well Tag#: BMS096 Customer: Paul Fiedler Depth: Site Address: 210 Arellem Rd, Union Depth: 320'275'5' Date of Test: 9118125 Pump Set: 320' TIME GPM LEVEL RECOVERY TIME LEVEL 1 Min 12 276.3 1 Min 276.7 �/L, 2 Min 12 2772 Min 276.5 , 3 Min 12 277.58 3 Min 276.4 spy 4 Min 12 277. 5 Min 12 277.9 4 Min 276.3 R 202 5 Min 276.2 �eF/VEQ 6 Min 12 277.9 6 Min 276.2 7 Min 12 278 8 Min 12 278 7 Min 276.28 Min 276.1 9 Min 12 278 9 Min 276.1 10 Min 12 278 10 Min 276 i, 15 Min 20 278 15 Min 276 20 Min 20 279.7 20 Min 276 25 M n 25 Min 20 279.5 30 Min 20 279.5 30 Min , 27 276 6 35 Min 20 279.5 5,9 40 Min 20 279.5 45 Min 20 , 279.5 50 Min 20 279.5 55 Min 20 279.5 1 Hr 20 279.5 Total Gallons Pumped: 1120 Gallons 11 Printed From Mason County DMS Printed from Mason County DMS ��,,,, Thurston County Environmental Health 1101P4: 412 Lilly Rd NE is Olympia,WA 98506 IV'-'- 360 867-2631 COUNTY ......e � COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sansple County Collected 1 _ I ._ _ ( ; MAU Ia., CI pm Mach Day Year Type of Water System(check only one box) pitPrivate Household 0 Group A 0 Group B 0 Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IDp — System Name: Contact Person: . , ,,; 'I, . Day Phone.( } - ,t i > Cell Phone ( ) E-mail: 1,,,s.c. .l, ,�, z t'1( „r.a. r.,rr Eve.Phone:( ) Send resin-to:(Print full'name,address and zip code a email addross) .rVt $LJ.i.. _..._.. - c ;'"e4kvI i kd SAMPLE INFORMATION Sample colected by(name). ` 'l:t i ' ,.u,,, Specific location or address where sample collected. -Special instructions or comments: iiL ' Ascllc, i lid z Type of Sample(must check'only ore box of el through k4 listed below) '•-0 Routine Distribution Sample 2.Repeat Sample(after tinsel routine) Chlorinated:Yes No 0 Distribution System Chlorine Residua:Total Chlonnated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total_.Free ❑E coin-GWR(A/P) ❑Fecal--somas,owl.songs Iw,t..t«+I Unsatisfactory routine lab number. . Feared Yes_®No _ ` _ — — CI Assessment Monitoring{*iP} Unsetiste,b.y routine coiled dale: ❑other t 1 4.0 Sample Collected for Information Only Investigative_ Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ti ltioma d ❑E.00li present 0 E.coii absent Replacement Sample Required: ❑Sanole too rid(>30 hours) ❑TNTC 0 Bacterial Density Results:Total CoAform /lOOml. E.coli _1100mi. - Focal Gallium it00mi Enterococci tt00 ml. Method Code: SM 92238 ❑SM 92220 Date and Time Received: (44 W 0 SM 92158 ❑Enieroted. 1 ..,_ - ice )4 )are end Time Anatyaad:1• L , Dale 371"1-9146.7 r,r+tr €r ri,100Ason f;ourlty DIMS w Know ki1i-itar,s...nn♦+Tim —. - ^ .