HomeMy WebLinkAboutWAT2025-00210 - WAT Application - 11/25/2025 WAT 202.5 - 00210
U415 N.6`11 Street
MASON COUNTY Shelton,WA 98584
t ICv(� 0-427-9670,Ext.400
4) Public Health & Human Services OL"i 1B lfa'iN40-275-4467,Ext.400
615 W.Alder Street
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 of Applicant: G J i -C/? '/ L66/_ . Date: /U/e/-.s
Mailing Address: v2)' Citgri S i-t-.c RP, Cliff:1/4 4t.L1 44 Phone: ,3 co- 2 i 4 - 3 712
Parcel Number: V,U05- • 3 - eon ce
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 1- Building permit
connections) 0 Division of land:
LI Individual water source (one connection), #of Parcels? SPL
fkl.-Well 0 Boundary line adjustment
0 Spring/surface water 0 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
0 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(i5/08/2024 Page I of 2
Group B Water Systems
I ' Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Water well report(attached to application). Depth J6 1 ft.
l Well capacity Test(attached to application)_ 17.5 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)
❑ Method of disinfection
Ir
❑ 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.
C.: 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: j F Date 11/25/25
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT CURRENT
Original&1'r copy-Ecology,2T°copy-owner,3t°copy-driller Notice of Intent No.W 354852
DCPAATMLNT OF
ECOLOGY Construction/Decontinission("x"in circle) Unique Ecology Well ID Tag No.BAR 168
M .of Washinton
® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION Property Owner Name Greg&Barb Elder
Notice of Intent Number
PROPOSED USE: El Domestic 0 Industrial 0 Municipal Well Street Address 1890 Phillips Lk.Rd.
0 DoWator 0 Irrigation ❑ Test Well ❑ Other
City Shelton County Mason
TYPE OF WORK Owner's number of well(if more than one)
El New well ❑ Reconditioned Method ❑ Dug ❑ Bored ❑ Driven Location ng1/4-1/4 �Nl/4 Sec¢ Twn 20� R 2_y_v EWM 0
❑ Deepened ® Cable 0 Rotary 0 Jetted (9,t,r Still REQUIRED) Or
El
DIMENSIONS: Diameter of woll 6 inches,drilled57 ft. WWM
Depth of completed well 67Lft. —
CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec
Casing El Welded s" Diem.from+1 ft.to §2 ft. Long Deg Long Mitt/Sec
Installed: 0 Liner installed " Diom.from ft.to ft. Tax Parcel No.(Required)22005 53 00068
❑ Threaded " Diam.From ft.to ft.
Perforations: ❑ Yes No CONSTRUCTION OR DECOMMISSION PROCEDURE
Typo of perforator used Formation:Describe by color,character,size of material and structure,and the kind and
SIZE of perfs_in.by—in.and no.of perfa_from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change
of information. (USE ADDITIONAL SHEETS IF NECESSARY.)
Screens: El Yes 0 No El K-Pee Location 50
MATERIAL FROM TO
Manufacturer's Name johnson top soil 0 3
Typo stainless Model No. br till 3 19
Diom.`3S1o1 size a from 62 ft.to 671t.
Dimn. Slot size from ft.to ft. br sand&gravel wet 19 42
57
coarse sand&gravel 42
Gravel/Filter packed: ❑ Yes ® No Size of gravel/sand water bearing
Materials placed front ft.to ft
Surface Seal: ® Yes 0 No To what depth?18ft. •
4
Material used in seal bentonite
Did any strata contain unusable water? ❑ Yes ® No _
Type of water? Depth of strata
Method of sealing strata off _____________
PUMP: Manufacturer's Namo poulds
Type:submersible H.P. 1
WATER LEVELS: Land-surface elevation above moan son level j ft.
Static levell2ft.below top of well Date 12-30-13
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,ete.)
WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump taut made? 0 Yes El No if yes,by whom?
Yield: gal./min.with_R drawdown after hrs.
Yield: ual./min.with_ft.drawdown after hrs.
Yield: gal./min.with ft.drawdown after hrs. __ •
Recovery data(thee taken as zero when pump turned o])(water level measured from
well top to water level)
Time Water level Time Water Level Timo Water Level
Date of test
Bailer test 3Q gal./min.with Eft.drawdown after abrs.
Airtest gal./min.with step,eel at ft for hrs.
Artesian flow g.p.m. Date 12-30-13 Start Date 12-23-2013 Completed Date 12-30-2013
Temperature of wator Was a chemical analysis made? 0 Yes El No
WELL CONSTRUCTION CERTIFICATION: I oonstruoted 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❑Engineer 0 Trainee Name(t'riat)Dwane Knapp Drilling Company KNAPP DRILLING INC.
Driller/Engineer/Trainee Signature Address 50 E LESACA DR.
Driller or trainee License No.1706 City,State,Zip SHELTON , WA., 98584
IF TRAINEE:Driller's License No: Contractor's
Driller's Signature: "--0 co 0�+ (Cp,i.p» Registration No. KNAPPDI952B1 Date 2/16/2014
7
HCY 050-1-20(Rev 02/10) If you need this document in an alternate format,please call the Water Resources Fragrant at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Greg Elder Well Tag#: BAR168
Site Address: 1890 E Phillips Lake Loop Rd, Shelton Depth: 57'
Date of Test: 11/24/25 Static: 12.2'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY
1 Min 17.5 17.9 TIME LEVEL
2 Min 17.5 18.9 1 Min 13.9
3 Min 17.5 19.1 2 Min 12.9
4 Min 17.5 19.3 3 Min 12.6
5 Min 17.5 19.4 4 Min 12.6
6 Min 17.5 19.4 5 Min 12.5
7 Min 17.5 19.4 6 Min 12.5
8 Min 17.5 19.4 7 Min 12.4
9 Min 17.5 19.4 8 Min 12.4
10 Min 17.5 19.4 9 Min 12.4
15 Min 17.5 19.5 10 Min 12.3
20 Min 17.5 19.5
25 Min 17.5 19.5
Total Gallons Pumped:437.5 De
TLib ao).5 - 01 15
I
I
I Thurston County Environmental Health
,�.r 412 Lilly Rd NE Olympia,WA 98506
" + TY 360 867-2631
TtlUR
, COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
7J Collected M ` yCr, ..jr .
1 ; s ❑PM
MoNh Day Year
Type of Water System(check only one box) 0 Private Household__.
❑Group A CIGroup B K_Other ! 1��(.1rWdi
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# ._- -- -- --
System Name:
Contact Person: C,re-? \(ASt,,�p
Day Phone:(3 ) 2 9- 3 7 7 Z. I Cell Phone:( )
E-mail: iGS,' 4pll tyi Eve.Phone:( )
Send rosu.ts to(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(naine):lo`-etS ¶�_(I fir,
Specific location or address where sarnplp collected: Special Instructions or comments:
13iiv E.:"?IV rA,l a'% 1..0.Js,Q...
Lon•44.:l •9/1-01k"
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unset.routine)
•
Chlorinated:Yes_-__.__No____. ❑
Distribution System
Chlorine Residual:Total Free___ Chlorinated:Yes —No_____
3.Raw Water Source Sample Chlorine Residual:Total_--Free__—_
❑E.coil-GWR(AIP)
❑Fecal-Sru tarn,owl•springs(numeratIoo) Unsatisfactory routine lab number,
Fltered:Yes____No__ —
❑Assessment Monitoring(AIP) Unsatisfactory routine collect date:
❑Other 1 ___—J-------
IS11
4.C&Sample Collected for Information Only
Investigative_--- Construction I Repairs x _ Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Conform Present and SatisfactoryColiform detected
0 E.cofi present ❑E.coli absent
Replacement Sample Required;
❑Sample too old(>30 hours) ❑TNTC 0_—_._. --
Bacterial Density Results:Total Coliform_._—_... /100m1. E.coli_.—.--
1100m1.
ItoOml Enterococci I100 mi.
Fecal Colform___ — ,7-�—:
•
Method Code::'SM 9223B OSM 9222D Date and Tkno Received:
❑SM 9215B 0 Entero!ert& 1•7 •;17 t)6c,.i
Date and Tkne Analyzed. 1 )-72' Dale Reported: 2 3 2 5 e+�'1
Sample Number(OOH number plus rnro 0'941) Lab Use Only: 0 59
0 8 0 (titti,r.t P
DOH arm''1.319(noised 11123) ..1