HomeMy WebLinkAboutWAT2025-00250 - WAT Application - 11/6/2025 WA'1' 2025-00250
04" . MASON COUNTY 415 N.6th Street
Shelton,WA 98584
Public Health & Human Services Shelton:360-227- ,East.400
Belfair:360-275-44467467;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: " r , --(31, x' Date: 1 I I (1912,C
Mailing Address: -\ E l L 4t t r b \fuLA Phone: DD— l 3518 p
Parcel Number: J l 2 e(o _al (1(0 �d 2
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 5d Building permit
connections) O Division of land:
0 Individual water source (one connection), #of Parcels? SPL
)QI Well •
O Boundary line adjustment
O Spring/surface water O Other(explain)
O Other(explain)
O 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)
❑ 1 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
J:\EH Forms\Drinking Water Revised 05/0812024 Page 1 of 2
Group B Water Systems
El Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
►1 Water well report(attached to application). Depth l ft.
Well capacity Test(attached to application)^ 15 __gpm >400 gpd.
The well driller often performs well capacity tests aT he 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
El WDOE permit(attach to application)
El 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)
IN 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:
ci AttnrAlioC°44'
Environ. Health: Date 1/9/26
This form may be scanned and available for public view at www.masoncountvwa.00v
Page 2 of 2
WATER WELL REPORT - o i DEPARTMENT OF Notice of Intent No. WE45093
ix"''' ECOLOGY Unique Ecology Well ID Tag No. BNX171
Type of Work: State of Washington
17 Construction Site Well Name(if more than one well):
O Decommission b Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: ❑' Domestic ❑Industrial 0 Municipal Property Owner Name Samantha&Jerry King
0 Den•atering 0 Irrigation 0 Test Well 0 Other
Well Street Address 71 E Lloyd Le
Construction Type: Method:
f New well O Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening ❑Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 22128-76-90082
Dimensions: Diameter of boring 6 in.,to 137 ft. Was a variance approved for this well? O Yes E No
Depth of completed well 137 ft.
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
DID 6 in. 0 133 0.25 in. ® I ❑ DI 0 Location(see instructions on page 2): ®WWM or O EWM
❑ I ❑ in. in. ❑ I ❑ DID SW Vi-Vs of the SW %;Section 28 Township 21N Range 2W
DID in. _ itt. ❑ I ❑ DID
❑ I ❑ in. _ _ in ❑ I ❑ OID Latitude(Example:47.12345) 47.276134
LLongitude(Example:-120.12345) -122.946984
Perforations: ❑Yes O No Type of perforator used
c
No.ofperforations Size of perforations in.by in.ea
Driller's Log/Construction or Decommission Procedure
L Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
3 Screens: (7 Yes 0 No 0K-Packer ' > Depth 131 R. information. Use additional sheets if necessary.
Manufacturer's Name Alloy Machine Works
to Type Stainless Slotted IodelNo• Material From To
'N
t Diameter 5 Slot size.016 in.from 132 ft.to 137 ft. Brown medium sand and gravel,loose 0 15
Co Diameter Slot size in.from ft.to 11. Brown silty sand and gravel,tight 15 50
Brown medium sand 50 56
o Sand/Filter pack:0 Yes 1]No Size of pack material in. Brown medium sand,wet 56 74
:F, Materials placed from ft.to-ft.
Gray silty clay 74 76
2 Surface Seal: a'l Yes 0 No To what depth? 18 ft. Brown medium sand,wet 76 93
o Material used in seal Bentonite Chips
C Did any strata contain unusable water? ❑Yes El Na Gray fine sand and silt 93 101
r- Type of water? Depth of strata Brown silty sand and gravel,wet 101 112
o
Method of sealingstrataoff Brown clay 112 114
c Multicolored gravel brown,fine to medium sand, 114
o Pump: Manufacturer's Name Type: loose,water 137
O H.P. Pump intake depth: ft. Designed flow rate: gpm
.
O Water Levels: Land-surface elevation above mean sea level 200 ft.
Stick-up of top of well casing 15 ft.above ground surface
} Static water level 76 ft.below top of well casing Date 11-3-21
y. Artesian pressure lbs.per square inch Date
= Artesian water is controlled by (cap,valve,etc.)
a
r— Well Tests:
a Was a pumping test performed? N No 0 Yes b by whom?
Yield—gpm with ft.drawdown alter hrs. -_ -- r.— }
I— Yield gpm with ft.drawdown after hrs. , 77 '' i :_..[1
O � '` '
Z Yield gpm with ft.drawdown after hrs.
ter d Recovery data(time=zero when pump is turned off—water level measured from well
o top to water level) t+AN 0 ) LU2I
Time Water Level Time Water Level Time Water Level J
u Ctl FCUIQC�/ (Jrr'11a
LU Date of pumping test
- Bailer test gpm with_ft.drawdown after hrs.
F Air test 25 gpm with stem set at 120 ft.for 1 hrs. Date 11-3-21
r Artesian flow gpm
ed
t Temperature of water 50 °F Was a chemical analysis made? 0 Yes Ml No Start Date 11-3-21 Completed Date 11-3-21
s-
ct WELL CONSTRUCTION CERTIFICATION: 1 constructed and/or accept responsibility for conslruction 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.
JO
a)
E Driller❑Trainee❑PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc.
I—
Sicense WCi y,St PO Bip x She90
License No.2874 Cit}',State,'Lip Shelton,WA 98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 11-3-21
ECY 050-1-20(Rev 09/18) lfyou need this document in an alternatefo mat,please call the Water Resources Program at 360-407-6872.
Persons with!tearing 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: Samantha&Jerry King Well Tag#: BNX171
Phone: 360-463-2245 Depth: 13T
Well Site Address: 71 E Lloyd Lane, Shelton Pump Set: 127'
Date of Test: 11/9/2021 Static: 75.2'
TIME GPM LEVEL RECOVERY
1 Min 12 78.7 TIME LEVEL
2 Min 9 78.7 1 Min 76.3
3 Min 9 78.6 2 Min 75.6
4 Min 9 78.5 3 Min 75.2
5 Min 9 78.5
6 Min 9 78.4 ,
7 Min 9 78.5
8 Min 9 78.6
9 Min 9 78.5
10 Min 9 78.4
15 Min 9 78.8
20 Min 9 78.8
25 Min 9 78.8
30 Min 15 78.8
35 Min 15 79.8
40 Min 15 80.5
45 Min 15 80.5
50 Min 15 80.5
55 Min 15 80.5
1 Hr 15 80.6
1 Hr 10 Min 15 80.7
Vanguard Laboratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
T�.srev.r:R r, 360-967-7010
•�.a„oat,,,.
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
/ Collected A
D( r�(� Z ❑AM1 J/1/1nt C G
Month Day Year
Ph
Type of Water System(check only one box)
/(�
O Group A ❑Group B I]Other Y U
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name: S .t el-1,
s,--
n: r Contact Persocadia Dri rng, n t... 7�
Day Phone Cell Phone:( )
Email: • Eve,Phone:( )
Send results to:(Print full name,address and zip code or e-mail)
-artets@eareediaririllirtsC rr[a*nrcadiadrinirs rom
. g,._(-1_1Z_ t/ _ 1 , .-- ------
SAMPLE NFORMATION
Sample collected by(name): se, l
SSjecific location where sam`plle collected: Special instructions or comments:
7 V i tJ›fr-1 �'LQ_
st fen, WA
ccuoTk s p ecce
Type of Sample(select only one type of sample from types 1 through 5 below)
1.O Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A/P)
Chlorinated:Yes No (from distribution system after unsat routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S I I I
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total Free
❑Assessment (NP)
4. Surface or GWI Raw Source Water Sample(Enumeration) I S J
❑E.coli O Fecal Filtered Yes_No
5.1]Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and W Satisfactory
O E.coli present O Ecoli absent
Bacterial Density Results:Total Coliform <1.0 I100ml. E.coli <1.0 /100ml.
Fecal Coliform /100m1. HPC /1 ml.
Replacement Sample Required: O TNTC O Sample too old
O Sample Volume O Damaged Container O
0 6/7Date/Time eived lab Reference Number —6:7Receipt Temp C": Method Code:
Date Reported to DOH Lab Use Only:
DOH Lab-Sample#
285- O(0bS
DOH Fenn F331.319(on'nu4e 0517)•11 you need this pob6oaani In an aaewlve format,al 900.525.0127(TD0/TTY cal 711) —
TNs and a'ler Irh:aEans re avaa la atwercdah.Iva 9mferin0 soots