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HomeMy WebLinkAboutWAT2025-00232 - WAT Application - 11/18/2025 WAT i:`r - CX' MASON COUNTY 415N.6tStreet Shelton,WA 98584 ' 21. Shelton:360-427-9670,Ext.400 ..s'� 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 Identifc Lion Name on Applicant: LION vti. ,J�vv�W�.vl Date: r D! ( 6 /2 S- Mailing Address: I 3 l 1 G Phone: 3L t'7--; / C.; — t/ DkA/ Parcel Number: e�F , SeN 4sZ — -- ..2. 1 9. - 1 1 - 1 GAG 9 I Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit 1:).4c c L O 1 I connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 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. llUrl [ — i L 'IkCd1� r " hGt Part 2: Water Connection Information �'" LtV I v c 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 1:\E1-1 Forms\Drinking Water Revised 05/08/2024 Paee I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ...X Water well report(attached to application). Depth 399 ft. 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. Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) O Method of disinfection O 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) IX 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. J 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: 11/18/2025 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.qov Page 2 of 2 3 • WATER WELL REPORT ta. DEPARTMENT 01' Notice of Intent No. WE59657 ECOLOGY Unique Ecology Well ID Tag No. BQC096 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission ,.._4 Original installation NOD No. Water Right Pennit/Certiftcute No. Proposed Use: IE Domestic 0 Industrial 0 hitter: al Property Owner Name Lenny Hohmann 0 ucwaering 0 Irrigation 0 Test Well 0 Other Well Street Address 18300 State Route 106 Construction Type: Method: ❑New well fd Alteration 0 Driven 0 Jetted 0 Cable Tool City Belfair County Mason ❑Deepening Li Other 0 Dug Ill Air- 0 Mud-Rotary Tax Parcel No. 22212-11-90091 Dimensions: Diameter of boring 6 in.,to 399 a. Was a variance approved for this well? 0 Yes 1 No Depth of completed well 399 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Tlmrad • 1 ❑ 8 tn. 0 390 .25 is 3 I ❑ f0310 Location(see instructions on page 2): 13 WWM or❑EWM ❑ I 0 _in. — — _in ❑ I ❑ ❑ I 13 SE 'A-'Y4 of the NE '4;Section 13 Township 22N Range 2W ❑ 1 ❑ in. J_ — in. ❑ 1 ❑ ❑ I ❑❑ 1 ❑ in. in. ❑ i ❑ ❑ I Latitude(Example:47.12345) 47.41574 N — — Longitude(Example:-120.12345) -122.86613 W Perforations: 0 Yes Oil No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Sin of perforulions_in.by in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from II.to 9.below ground surface nature of the material in each layer penetrated,with et least one entry toe each chaogc of Screens: OA Yes Cl No lit I:-Packer r Depth 388 It infornation Use additional sheets if necessary. Manufacturer's Nome Alloy Machine Works Material From 'I•o Type Stainless slotted Model No siltysand and gravel 0 5 Diameter 5_ Slot size.000 in.front Brown 389 R.to 394 ft, Diameter S_ Slot size.030 in.from 394 file 399 ft• Brown clay,sand and gravel 5 30 Brown medium sand 30 41 SnrullFllter pack:0 Yes F]No Size of Fick material_in Brown silty sand and gravel 41 58 Materials placed from ft.to ft. 58 252 Gray clay _ Surface Seal: 1 Yes LI No To Malt depth? 18 ft. Brown silty clay,few gravels 252 314 Material used in seal Bentonite chips Brown silty clay with lenses of sand,wet 314 337 ___ Did any strata contain unusable water? U Yes E:.1 No Type of water? Depth of strata__ _____ Brown fine sand,silt,water 337 387 \Icttuod of scaling strata off Brown silt,dry 387 389 Multi-colored gravel,brown medium sand,loose, 389 — Pump: Manufacturer's Name Tye water 399 I1.P. Pump intake depth:_—6. Designed flow tate: ppm — Water Levels: Land-surface elevation above mean sea level 213 11. --— — Stick-up of top of well casing 2 11.above ground surface Static water level 113 ft,below top of well casing Date 5/8/25 Artesian pressure lbs.per square melt Date Artesiun water is controlled by (cap,saes:,etc.) -----------Well Tests: Was n punyring test performed? El No 0 Yes r- ' by whom? _ -- Yield gpm with—tl.drawdown after_hrs. Yield gpm with It.drawdown after_ _hrs. Yield gpm with_ft.drawdown after hrs. T Recovery data(time=zero when pump is tented off water level measured from well top to water level) fine 1\'nter Level1'iue Water Level Time \vmer Level — Date of pumping test — Bailer test gpm with_I1.drawdown eller hrs. Air test 30 gpm with stem set at 360 Ii.for 2 bra. Date 5/8/25 i Artesian flow gpm .1 Temperature of water 50 "F Was a chemical analysis made? 0 Yes ©No Start Date 5/7/25 Completed Date 5/8/25 WELL CONSfRUCfION 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 are true to my best knowledge and belief. E)Driller 0 Trainee❑PE—Print Nmne s oepp Drilling Company Arcadia Drifting Inc. Si nature Address PO Box 1790 License No.2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsors License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/8/25 • ECY 050-1-20(Rev 09/18) If you need this document in an alternate formal,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can ca11877-833.6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98684 Customer: Lenny Hohmann Well Tag#: BQC096 Site Address: 18300 State Route 106, Belfair Depth: 399' Date of Test: 0611612026 Static: 113.4' Pump Set: 340' TIME GPM LEVEL RECOVERY 1 Min 9 116.2 TIME LEVEL 2 Min 9 116.4 1 Min 114 3 Min 9 116.4 2 Min 113.8 4 Min 9 116.4 3 Min 113.7 5 Min 16 116.4 4 Min 113.6 6 Min 16 116.8 5 Min 113.6 7 Min 16 116.9 6 Min 113.6 8 Min 16 116.9 7 Min 113.6 9 Min 16 116.96 8 Min 113.6 10 Min 16 117 9 Min 113.6 15 Min 16 117 10 Min 113.6 20 Min 16 117 • 25 Min 16 117.1 • 30 Min 16 117.2 35 Min 16 117.2 40 Min 16 117.2 45 Min 16 117.2 50 Min 16 117.2 55 Min 16 117.2 1 Hr 16 117.3 1 Hr 10 Min 16 117.3 'Total Gallons Pumped: 1026 I 1- i i Vanguard Laboratory . 2635 Parkmont Lane SW,Suite A Olympia WA 98502 vtd4gett m 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected lime Sample County Collected ID AM Mason 04/16/2025 i 2 o ®PM Abnth Day Year Type of Water System(check only one box) 0 Group A 0 Group B ®Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFl): IDS i li System Name: Lenny Hohmann i Contact Person:Arcadia Drilling,Inc Day Phone:(360 )428-3305 I Cell Phone:( ) Email: Eve.Phone:( ) i Send results to:(Pant full name,address and zip code or e•maf) attetegarcediadriling cam AND)ennaarcadledrilling.com _______ _. _� -: . SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Special instructions or comments: 1 BQC098-18300 WA-106,Belfair i ` Type of Sample(select only one typed sample from types 1 through 5 below) 1.❑Routine Distribution Sample(AIP) 2.0 Repeat Sample(AP) Chlorinated:Yes NO (from dlstdbuton system attar unsaL routine) Unsatisfactory routine lab number. III Chlorine Residual:Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: ts t l 1 I I I I Chlorinated:Yes No 0 Triggered(NP) Chlorine Residual Total___-Free I i CI (A/P) _.. 4. Surface or OWI Raw Source Water Sample(Enumeration) S 0 E.cog ❑Fecal Moral Yea No 5.®Semple Collected for Information Only: 1 LAB USE,ONLY DRINKING WATER RESULTS LAB US .ONLY ❑Unsatisfactory Total Califon Present and I (I Satisfactory ❑E.cofi present 0 E.col1 absent i Bacterial Density Results:Total Coliform 1100ml. E.coli 1100m1. Fecal Coll form _J100ml. HPC __.11 ml. 1 Replacement Sample Required: 0 TNTC 0 Sample too old I ❑ Sample Volume ❑Damaged Container 0 { Date Imo voted: Lab Reference Number t' VI6 o-i'S4 \Ias,o-kV'-\ l Rece pl Temp C': Method Code: 1 1e'0 SM9223B Dale Reported to DOH Lab Use Only: 1 04/21/25 DOH LabSample# 285-04171 iDOH Fan a»aw ten a s OW)•a you rood Kap.Okada n e+onmee a Vent a1 MO 325ot27 A oorr7Y ml it 11. I T14end On pubkaYene we miens*WWI dMnovdaiNUgreate•. I