HomeMy WebLinkAboutWAT2025-00149 - WAT Application - 10/29/2025 d C I1NTT N
•
RECEIVED
WAT 2025 - oo I.99
JUL 22 2025
• . `j MASON COUNTY A/1 415 IC.61t'Street.
Public Health & Human Services Hclfair: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 on Applicant: JUL I A N tv Bo Date: •
Mailing Address: 1012 S. . P h 14LIPS 120 . Phone:
Parcel Number: 32035-'5 - 0 0 t t o
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑ Building permit
nections) 0 Division of land:
Individual water source (one connection), #of Parcels? SPL
0 Boundary line adjustment
0 Spring/surface water 0 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.
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
IN Water well report(attached to application). Depth 155 ft.
® Well capacity Test(attached to application) 10 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).
_ 1
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.
0 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: S 10/29/25
Date i
This form may be scanned and available for public view at www.masoncountywa.gov
Nag:,2 ore
WATER WELL REPO DE.PAO.D44far Of Notice of Intent NE040S
ECOLOGY Unique Ecology Well ID Tag faRR 186
Type at Work: Vau'o+Wa,eningior+
• Construction
Site Well Name(if more than one we'll:
O Decommissiotr-* Original installation NO1 NO Water Right Permit/Certificate No
Proposed Use: •O Domestic 0 industrial 0 Municipal Property(honer Namduliann Burns
U Dewatering LI ltrigation Cl Test Well ❑Oth..r Well Street Addie,d 012 SE Phillips Rd
Construction Type: Method:
fr1 New well ❑Alteration 0 Driven ❑Jetted 0 Cable ToolCtty Shelton County Mason
0 Deepening ❑nthar ❑Dug ' ❑Air- ❑Mud-R.taryfax Parcel No 32035-75-00110
Dimensions:Diameter oflwrit ._._ in..to157 ft Was a variance approved for this well? ❑ Yes ❑No
Depth of completed welt55 ti.
If yes,what was the variance for'
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
N I 0 y +1 15f. 0 I 0 0 I 0 Location(see instructions on page 21: • 0 WWM or 0 EWM
▪ 0 ...........in. — — •---m` 010 ❑ I ❑ SE._ vi-!';of they '/,;SScevna5 Townsain Rao_
❑ l ❑ in. —in.in, 10 ❑ 1 ❑❑ 1 ❑ in. — _ in. 010 ❑ 1 LatitudeIExample:47.121d4T-17143
Longitude(Example:-120.1214493 01624
Perforations:0 Yes Le No Type of perforator veil Driller's Log/Construction or Decoatutnission Procedure
No.of perfc>raiiooi Size of pertotatiotii_ ill.by m Formation:Describe by color,character,size of material and structure,and the kin_and
Perforated fmur_ ft_3o_ ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of
Screens: f i Yes iJ No CI K-Packet} MOM. ft. information.Use additional sheets if necessary.
Manufacturer's lvainStainless Steel Material From To
Type Jo°tnson Model No.Diametea—__ in. Slot sid rla tt?10 in.fro ft. 1
Clay.Top oil).some oravel. brown/soft 1 soil 0 1
Diameter in- Slot sizes_ in.froth,__ 'Lao-- ft.
7
Clay,silt, silt.sand,gravel,brown/soft 7 15
Sand/Filter pack:La Yes•❑No Size of pack material— in. Sand,gravel,silt, brown/soft 15 25
Materials placed from tie_ ft. Sand,some oravel,silt, araY/soft 25 36
Surface Seal:s0 Yes U No To what depth"i$_ fi. Sand,gravel, silt.little water,gray/soft 36 43
Material used in seaBentonite Granular Clay,some gravel,gray/hard 43 52
Did any.strata contain unusable water'? Yee C No 52 128
Type of water? Depth of strata. Clay,gray/soft
Method of sealing strata otl• Sand,silt,some clay,gray/soft 128 134
Sand.gravel, silt,gray/soft,wb 134 155
Pump: Manufacturer's NarkiiA Type Clay,pray/hard 155 157
11.p Pump intake depth tl. Designed tbwsate_ gm
Water Levels:Land-surface elevation above moan sealcYel ft.
Stick-up of top of well casja . ft.above ground surface
Static water lever ft.below top of well casittlitate 9/5/2025
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap.valve.etc.)
Well Tests:
Was a pumping test performed?Li No U Y '.' by wham?
Yield_gpm with,_, ft drawdown antra._ hrs.
Yield_ gpm with........ fi.drawdown after_ hrs.
Yield,— gpm with__ ft.drawdown aftM hrs.
Recovery data(time-zero when pump is turned off-water level measured fin n well
top to water level)
Time Water Level Time Water Level Time Water Level
—l' Date of pumping test
Bailer test_.. gpm with__ ft.drawdownaticc hrs.
Air test t_gpm with stem set tUk... ts. 91E12025
Artesian flour gpm J1J
Temperature of water "F Was a chemical analysis made? ❑Yes D No Start Date 9/5i2025 Completed Data/5/2025
WELL CONSTRUCTION CERTIFICATION: I constructed and-or accept responsibility for construction of this well.and its compliance with all
construction standards.Materials used atidliianation reported above true to my best knowledge and belief.
47:Driller0 Trained 3 PE-himName Chris Jones Drilling CompattMoerke&Sons Pump and Drilllna
Signature t. 4_2._ 11+Mt._ Address1162 NW State Avenue
License No.2253 City.State.Zi6hehalls.WA 98532
IF TRAINEE:Sponsor's License No. Contractor's
Svonsvr's Signature Registration NJAOERKSP072N5 Dato9/5/2025
ECY 050-1-20(Rcv I Ill S)If you a need this document in an alternate format,please call the Water Resources Program at
$M)-407-6R72, Persons with Gearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call
R 77-Rai-n341.
al
MOERKE & SONS PUMP & DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805
PUMP TEST
JULIANN BURNS 10/28/2025
P.O BOX 1333
MCCLEARY, WA 98557
WELL SITE ADDRESS: 1012 SE PHILLIPS RD, SHELTON
Pump Make & Model: 1 Pump Set At: 140'
Sounder Make& Model:
Make & Model: Measured in: GALLONS
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 12 152687 62'
1 12 152699 65'
2 12 152711 67'
3 12 152723 69'
4 12 152735 71'
5 12 152747 72'
6 12 152759 73'
7 12 152771 73'
8 12 152783 73'
9 12 152795 73'
10 10 152807 73'
15 10 152857 73'
20 10 152907 73'
25 10 152957 73'
30 10 153007 73'
35 10 153057 73'
40 10 153107 73'
45 10 153157 73'
50 10 153207 73'
RECOVERY
0 73'
1 71
2 69'
3 67'
4 64'
5 62'
SIGNATURE:
0 UMP AND DRILLING
Vagaora Lobastary
V 265 Pathos*Ism SW,Suite A
otpripia WA 9g502
360-9674010
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