HomeMy WebLinkAboutWAT2025-00248 - WAT Application - 11/17/2025 WAT ,2,,T -.�- ,,)_ -ell ,
MASON COUNTY 413" `'1'S""'
Shelton.WA 98584
ins Shelton.360-427%70.Ext.400
vi'. ;.. .7 k Public Health & Human Services &flair: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 of Applicant: 6-R,26- fi 1...0UA6e, pv:f.rQ?idy:. Date: /.2. .JI . .,%—
Mailing Address: 3 6i1 (J,00R:7- R.[a Phone: ja/, 9i d ioat.
Parcel Number 3 36- 7'i• gQDur-
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more ,21' Building permit
connections) 0 Division of land: i
kr Individual water source(one connection), #of Parcels? SPL
Z Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
0 Other(explain) 0 Replacement or Remodel(please indicate name a
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.
e
Part 2: Water Connection Information cE
r
Complete the section appropriate for the type of water connection being evaluated:
Public Water System II
i
e
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 I
connection on this system(i.e.: recreational to full time). Please indicate on the following line the nature of t
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.00v
1_AHI Fumii1 Drinking Water Rowed tri!pW2074 1'agc I of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
/ Water well report(attached to application). Depth /L e V ft.
yf Well capacity Test(attached to application) 1(3 gpm 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.
l
Satisfactory bacteriological test within last year(attach to application).
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)
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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: 12/17/25
Environ. Health: � W� Date
This form may be scanned and available for public view at www.masoncountvwa.gov
_Y._ Vanguard Laboratory
2635 Parkmont Lane SW.Suite A s
Olympia WA 98502 I
.,,F„,,.•r. 360 967-70I0
COLIFORM BACTERIA ANALYSIS FORM i ..
Date Sample Coaecaad Toe SamGr I County
Collected � , Mason
10/06/2025
_____Ill tv
Fart Da Yu, -.
Type of Water System(dtedr only one ba) It
0 Grout)A 0 Group a I!Other----_
Group A and Group B Systems-Provide tom Water Fates wry(►FI)-
SystemName Louise Bartol i
Contact Person Arcadia Dolling.Inc
Day Phone(360 )426-3395 Cell Phone-( )
Email Eve Phone( ) —
Send re$*s ID';Port to name warm and rip cote a e+nail1
adc••agarcedra3wng.con ANO nenraarUdeaorang corn
I
SAMPLE INFORMATION
sample coke ed by(name):Max —
Speck bwoon where sample collected Spec rnsouctidns or comments I,
BOC189-160 SE Ashley Rd,Shelton Counts please I
• Type of Sample(select only one type of sample from types I through 5 below) Et
1 ❑Routine Distribution Sample(A!P) 2.❑ Repeat Sample(All))
(tram riGuiN bon system otter onset routne)
Chlorinated:Yes No Unsatisfactory routine lab number Itt
Chlonne Residual.Total__Free-- - — 1
3 Ground Water Rule Source Sample Unsatisfactory routine collect date.
1 S I ! I _.
Chlorinated Yes No_---
❑Triggered(AR) Chlorine Residual'Total Free_..
❑Assessment (NP)
',1 4 Surface or GWI Raw Source Water Sample(Enumeration) I S i 11
❑E cob 0 Fecal F 9s•0 Yes.,__.-Nor._
5 MI Sarrc.e Collected br Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and 1 M Satisfactory
❑Eta present ❑E cob absent
Bacterial Density Results Total Califon <1.0 /10Ornl.Ecat <1.O 1100m1.
Fecal Cordorm -___1100m1 HPC__ it ml.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume ❑Damaged Container 0 --
OatT Rate� Lao esterence flume(
to�oie ` 1094 Ua�100`l -3
RemA Temp c.. mew Code:
er2 343
Case RacCad 13 DOH Lao Use Orly
DON LaDSamolea
285- 1001 3
i Case ra41t9(llrreWel•0 p re YreYoen w am rgbLeet y KID slow r'tdrt.m"
'b arR Ow'deeeuns I raids dam soma isOrftripem
IM
1
it
WATER WELL REPORT
<,s; DEa.4="MIIII" C- Notice of Intent No WE60828 1
ECOLOGY _—
UnItl Fceloay Well ID Tat No BoC189
Type of ll ark: Site Well Name(t(more than one well) -
`. Construction i
J Dceominissinn c ()name]msullatiaa NOI No Water Right Permit/Certificate No ----- M
Proposed t`x: -T_Doreen O tndutirsal -'.Municipal Plt,f,srty Ossner Name Louise Bartol II
Dewaarat= Ll lineation 0 Test mien -Other Well Street Address 160 SE Ashley Rd -- d
Cowsnvesion Ty Method•
re, City Shelton County Mason _
New well :_.\lterarwn C 0tnen ❑kited Cable Too)
Deepening ()they - �,Dull R.5,r. C\furl-Rotas Tax Parcel No 32035-75 s90052
I
Dimensions: Diameter of boxing 6 in.to 170 n Was a variance approsed for this well' 0 Yes 0No it
r
Depth of compacted well 169 nI
if yes.what was the variance for'.__- 11
Cons illation Derails: Wail a
Casing Liner Diameter From To Thickness Steel PVC Welded Thread [WWM er f E�1 M
3 ` 6 in 0 � .25 in. 3 G e"] t 0 Location(see instructions on page_) ii
O ;_ _in _ _ ,__in. G O O 1 ❑ NW .of the Vs:Section 2 Township 19N Range 3W a
0 I C in ,- in D 1 G D I G Latnudc(Ecample:47.1'_34i)4717021 N a
Longitude(Example.•120 1'_345) 123 01982 W
Pertentiaa 0 Yes s No Tape otperfaa err used Driller's Log/Construction or Decommi sioe Procedure
No of perforations— Sue of perforations in by. m Fsxnunon Dcscnbe In color character,size of material and strutitve.and the kind and
Perforated from fi.to 6 Delow ground surface nature of the material in each layer penetrated w ula at least one era!'foe each change of
Screens: i Yes ❑No I K•Pa_kcr C Depth 163 ft
information L'se additional sheets%Ince:sun
Manufxwcr's Name Alloy Machine Works Material From To
Type Stainless slotted Model No Drown silty sand 0 3
Diameter 5' Slot sue.020 in from 164 fi to 169 ft Brown
26
Diameter Slot site—in.from _ft to ft Brown silty sand.gravel 69 .
Brown silty sand,tight 26
Saud/Filter pack:=Yes S.No Site of pack material in. Brown silty sand,gravel 69 91
Materials placed from ft.to_6 Gray silty day,sand.gravel 91 114 ,
Surface Seal: I Yes ❑No To what depth" 18 ft Brown medium silly sand,gravel.wet 114 125
Material used in seat Bentonite chips Gray silty clay.sand.gravel 125 136 ,
. Did any strata contain unusable water' O Yes it No Gray silty clay 136 139
Type of w ater' Depth of strata Blade sand,gravel,water 139 169
\tathod of sealing orata off Gray clay 169 170
Pump: Manufacturer's Name type-
}{P. Pump intake depib:__ft Designed Doss-rale:—rpm
Water Levels: Land-surface des anon'time mean sea Its el 167 ft
Sock-up°flop of well cuing 1_5 ft abose ground surface
Siam water les el 119 ft below top(Audi casing Date 9/24/25
Artesian pressure lbs.per square inch Date
Artesian water s controlled b' (cap.vats e etc)
11 en Tests'
Was a pumping test performed' No D Yes by whom'
Yield_gpm tr'ith ft draw down after_his
Yield_gpm with—ft draw down after__his
Yield _gpm w sth ft draw down after___hrs.
Roemery data(time-zero when pump is turned off water lcs et measured from well
top to water level)
lime Water I.riot Tonne %%tierr l.escl Tune wacr LCssI
Date of pumping mu
Baler test_gpm with_ft draw down after hrs }
Air lest 35 gpm with stem set at 1150 D for 1 his. Date 9124)25
Artesian now rpm
Temper/tun of w ado 50 'F Was a chemical analysis made' _Yes !r No Start Date 9f22/25 Completed Date 9/24/25
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well.and its compliance with all V4'ashingron%sell
construction standards Materials used and the information reported abor e arc true to my best knowledge and belief
0 Driller C Ira' PE-Pr a James Johnson Drilling Company Arcadia Drilling Inc.
Signature 1 Address PO Box 1790
License 3479T City.State.Zip Shelton.WA 98584
IF TRAINEE Sponsor's License No 2874 Contractor's
Sponsor's Signature / Registration No ARCADDI098K1 Date 912425
ECY 050-1=0(Rex 09i I8) if)ou need this document in an alternate prison.please call the Water Resources Progrmrr at 360-407-6872.
Persons with laeonng loss can coil 711 for Washington Relay Sen'rce. Persons it oh a speech disability can call8i7-833-6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Well Tag#: SgC189
Customer: Louise Bartol 169'
Site Address: 160 SE Ashley Rd, Shelton Depth:Dh: 119'
Date of Test: 1010612025 Pum• Set: 150'
TIME GPM LEVEL RECOVERY
TIME MUM
1 Min 3 109
1 Min 128
2 Min 7.5 109.7 2 Min
3 Min 7.5 110
3 Min 126.1
4 Min 7.5 110.5 5 Min 15 1 4 Min 125.1
10.8
6K2n 15 111.8 5
6Min 124.5
5 Min 12
7 Min 15 112.6
113.1 7 Min 124
8 Min 15 9 Min 15 113.8 8 Min 123.7
10 Min 19 114.1 9 Min 123.5
15 Min 19 117.5
10 Min 123.4
20 Min 19 119.8
25 Min 19 121.6
30 Min 19 123.1
35 Min 19 124.6
40 Min 19 125.6
45 Min 19 127
50 Min 19 128
55 Min 19 128.8
1 Hr 19 129.7
1 Hr 10 Min 19 130.5