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HomeMy WebLinkAboutWAT2025-00253 - WAT Application - 1/15/2026 WAT 2025-00253 MASON COUNTY 415N.6', Street Shelton,WA 98584 Public Health & Human Services Shelton:360-427-9670,Ext.400 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 Identification Name of Applicant: Val and Iris Nielsen Date: 12/17/25 Mailing Address: 2629 Aberdeen Ave., Hoquiam, WA 98550 Phone: 360-580-5847 Parcel Number: 61905-75-00010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more K Building permit BLD2025-01370 connections) ❑ Division of land: 1 Individual water source (one connection), #of Parcels? SPL p 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) O 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. O 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 Water well report(attached to application). Depth 78 ft. 9 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 33 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. C 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/cr 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) :L 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. i_:_; 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: i,tz 1/15/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 -� WATER WELL REPORT CURRENT original&t'copy-Ecology,2w copy-owner,3"t copy-driller Notice of Intent No.WE28879 DEPARTMENT Of EC,OL9 Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No.BJT852 l$• , _,,, 2018 ® Construction Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATION '',I.e., Deett It nt Notice of Intent NumberProperty Owner Name VAL NEILSEN PROPOSED USE: of Domestic O Industrial O Municipal Well Street Address 71 W SATSOP BRIDGE RD O DeWater O Irrigation O Test Well O Other City EL 1A County MASON I TYPE OF WORK: Owner's number of well(if more than one) Locution SW ll4-1/d SW l/4 Sec 5 Twn 19N R 6 EWt4I O ® New well O Reconditioned t4ethoel-O Dug 0 Bored 0 Driven ❑ Deepened 0 Cable El Rotary O Jetted (a,I,r Still REQUIRED) Or ti4 W'rl El DIMENSIONS: Diameter of well 6 inches,drilled 80 ft. Lat/Long Depth of completed well 78 tt. Lat Deg Lat Mitt/Sec CONSTRUCTION DETAILS Long Deg Long Min/Sec Casing : Welded .' Diem.from#2 it to 78 ft. Installed: O Liner installed [Siam.from ft.to ft_ Tax parcel No.(Required)61905-75-00010 "' O Threaded " Diiam,From ft,to ft. ' Perforations: O Yes ® No CONSTRUCTION OR DECOMMISSION PROCEDURE Y Type of perforator used Formation:Describe by color,character,size of material and structure. 8 SIZE of perfs min.by_in,and no.of _ from^ft.to_ft. and the kind and nature of the material in each stratum penetrated,with at a least one entry for each change of information. (UST ADDITIONAL 77) Screens: O Yes ® No O K-Poe Location SHEETS IF NECESSARY.) Manufacturer's Maine MATERIAL, FROM TO '1" Type Model No. PEAT LOAM 0 3 4- [Slant. Slot size from ft,to ft. BROWN CLAY GRAVEL 3 40 c Diem. Slot size from ft.to ft. BLUE CLAY GRAVEL 44) 60 .2 Gravel/Filter packed: O Yes ® Na Size of gravel/sand GRAVEL SAND WB 60 80 f Materials placed from ft.to R NSurface Seal: != Yes O No To what depth?2Oft. i material used in seal 3/8 BENTONITE CHIP Did any strata contain unusable water? O Yes 12 No O Type of water? Depth of strata Method of sealing strata off cPUMP: Manufacturer's Name itl ei Type: H.P. WATER LEVELS: Land-surface elevation above mean sea level ft. t' Static level ft,below top of welt Date If Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) 1• WELL TESTS: Drawdown is amount water level is lowered below static level O Z Was pump test made? O Yes ® No if yes,by whom' • 'a Yield: gal./min.with ft.drawdown after hrs -o Yield: gal./inin,with ft,drawdown after hrs. Yield: gal./min.with tt.drawdown after hrs. • o ` Recovery data(lime token on zero when pump turned off)(water level measured1m m to well top to water level) t Time Water Level Time Water Level Time Water Lewd - I o o. d a Date of tee: • I • I- Bailer test gal./min,with_ft drawdown after_hrs. • Airiest 33 gal./min.with stem set at 77 ft.for I hrs. Artesian flow g.p.m. Date Temperature of water Was a chemical analysis made? ❑ Ye ® No Start Date 04/26/18 Completed Date 04/26118 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards. Materials used and theinfo5mation reported above are true to my best knowledge and belief. kJ Driller O Engineer O Trainee tame(1:ri OBERT LAYM©N Drilling Company ADVANCED DRILLING Driller/Engineer/Trainee Signature /' .,-a-a'�`�' — Address 11531)SCHOOL LAND RD SW Driller or trainee License No.2588 l—'-�` City,State,Zip ROCHESTER . WA, 98579 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. ADVANDLS7IQE Date 04/30118 ECYOSO-1-20(Rev 02-2010) To request ADA accommodation including materials in a format for the visually impaired,call Ecology Water Resources Program x1360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341. Grays Harbor Equipment 410 South F St. Aberdeen, WA 98520 Ph.(360)532-8643,Fax(360)532-8646 WA Lic. # GRAYSHE935CE Customer: Val &Iris Nielsen Well Tag# BJT852 Phone: 360-580-5847 Depth : 80' Well Site Address: 71 W Satsop Bridge RD Pump Set: 75' Date of Test: 12JAN2026 Static: 53' TIME GPM LEVEL 1 Min 15 53.0' 5 Min 15 56.5' 10 Min 15 56.5' 15 Min 15 56.5' 20 Min 15 56.5' 25 Min 15 56.5' 30 Min 15 56.5' 35 Min 15 56.5' 40 Min 15 56.5' 45 Min 15 56.5' RECOVERY -- TIME LEVEL 1 Min 55.0' 2 Min 53.6' 3 Min 53.0' Thurston County Environmental Health 412 Lilly Rd NE ill Olympia,WA 98506 ` 360 867-2631 THURSTON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County //} f,6 Collected Month Day Year ! V(s—d Pty `s' Type of Water System(check only one box) Private Household ❑Group A ❑Group B ❑Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: ‘,1Pc(_ JJ Day Phone: ) ^f Cell Phone:( E mail:}�E stavorapt I r .„3 � ) Send results to:(Print full name,address and zip code or email address; SAMPLE INFORMATION Sample collected by(name). lamPkt Specific location or ad resT-0ere sam iq a coll`ectpd:r SXlal instructions or comments £t*4 iv/ LJ, Type of Sample(must check only one box of#1 through#4 listed below) 1.O Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated,Yes No Distnbution System Chlorine Residual:Total Free_ Chlorinated:Yes No, 3.Raw Water Source Sample Chlorine Residual:Total_ Free_ ❑E.coil—GWR(A/P) O Fecal—Surface,Gwl,springs(numerafon) Unsatisfactory routine lab number: Filtered:Yes No _— _�— ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other S 4.❑Sample Collected for Information Only Investigative_ Construction/Repairs __ Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY O Unsatisfactory Total Coliform Present and Satisfactory O E.coli present O E.coli absent No oliform detected Replacement Sample Required: O Sample too old(>30 hours) O TNTC O Bacterial Density Results:Total Coliform_ /100m1. E.coli _/100ml. Fecal Coliform /100ml Enterococci /100 ml. Method Code:( 6M 92238 ❑SM 9222D Date and Time Received:/03S O SM 92158 O Enterolert® 1 Date and Time Analyzed: — ., Dale Report+(3 ✓ Sample Number(DOH number plus five digits) Lab Use Only: °S 0 8 0 DOH Form S331.319(revised 11{23 / ) 9