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HomeMy WebLinkAboutWAT2025-00247 - WAT Application - 1/26/2026 WAT 2025-00247 MASON COUNTY 415N.6`hStreet Shelton,WA 98584 Shelton:360-427-9670,Ext.400 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 Identification Name of Applicant: 41O# T& e(AU 4 Date: /1/1--/9:-.2c Mailing Address: '007 5 �d ,ST. W ,,Phone: Zcj 3 •'332 . DO o 7 Parcel Number: 2 2 aO3/2— 900 V•S/ 4/NiV6Srt' /x/46 i AM- 9t '17 Type of Water System Reason for Application 0 Public/Community Water System (2 or more Eilletuilding permit connections) 0 Division of land: gifIndividual water source (one connection), #of Parcels? SPL 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 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 J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well IB/Water well report(attached to application). Depth 96_ ft. 4-14.2 >400 gpd. C� Well capacity Test(attached to application) 6. _ gpm 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 ❑ 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. C1 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: h2 S 1/26/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT X"�1 DEPARTMENT OF Notice of Intent No. WE53730 •_,--...s.._ r ECO LOGY Unique Ecology Well ID Tag No. BPF061 Type of Work: State of Washington E l Construction Site Well Name(if more than one well): O Decommission rr:=, Original installation NOl No, Water Right Permit/Certificate No. Proposed Use: CI Domestic ❑industrial O Municipal Property Owner Name Jon ZUrfIUh ❑Dowatering O Irrigation ❑Test Well O Other Well Street Address Off Bergeson Rd Construction Type: Method: gl New well O Alteration O Driven ❑Jotted O Cable Tool City Shelton County Mason CI Deepening O Other O Dug 0 Air- O Mud-Rotary Tax Parcel No. 22003-12-90044 Dimensions: Diameter of boring 6 in.,to 99 ftWas a variance approved for this well? O Yes ©No Depth of completed well 96 ft• if yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread [`I�tNAM or O EWM p i a s in. U 92 .025 M. RIO Ell ❑ Location(see instructions on page 2): ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ SW y,-%.of the NE '/,;Section 3 Township 20N Range 2W ❑ l ❑ in. _._.•. in. ❑ I ❑ Q ' ❑ Latitude(Example:47.12345) 47.254396 N ❑ ❑ in, in. ❑ O ❑ ❑ _... Longitude(Example:-120.12345) -122.917284 W Perforations: 0 Yes GI No Typo of perforator usedNo. Driller's Log/Construction or Recommission Procedure Perforated ofped ficm perforations -_ Size of ground _ _in.by_ _ 'n• Formation:Describe by color,character,size or material and structure,and the kind and fiom ft.to w ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of ®K-Packer Depth 90 it. information. Use additional sheets if necessary. Screens: f7 Yes O No Material From ' To Manufacturer's Name Allo Machine Works 0 9 Type Wire wrapped Model No. Brown gravelly fine sand,loose,dry Diameter 6_ _ _ Slot size.02o in.from 9;t to ft to �6 ft. Black gravelly fine sandy silt,tight,dry 9 18 Diameter Slot size�_�_is from _ ft• Chocolate peat,stiff,dry 18 • 19 SaBlack gravelly fine sandy silt,cemented,dry 19 24 Materials als pack:❑Yes C•7 No Size of pack material in. 19 Materials placed from __ R.w ft Brown fine sandy gravel,silt bound,tight,dry 24 32 —Surface Seal: J Yes El No To what depth? 20 ft. hardpan 32 41 Material used in seal Bentonite chips Brown fine to medium sandy gravelsiity,tight,dry 41 44 Did any strata contain unusable water? O Yes le No Type of water? Depth of strata Red silty clay,stiff,dry 44 53 Brown fine sand,tight,dry Method of sealing strata off Gray sticky clay,dry 53 58 : Type: Black fine to medium sandy sharp,gravel,tight 58 — Pump: ivfanufactwee's Name 64 MP. Pump intake depth _ft. Designed flow rate: grim Water Levels: Land-surface elevation above mean sea level 43 ft. Black fine sandy sharp gravel,gray silt binding, 64 76 Stick-up of top of well casing 1 ft.above ground surface cemented,dry 86 Date Static water level 44 R.below top of well casing 10/13/23 Black gravelly fine to medium sand,tight,wet 78 Artesian pressure_lbs.per square inch (cap valve,etc.) Black gravelly fine sand,heaving,wet 86 93 Artesian water is controlled by Black coarse sandy gravel,loose,water,heaving 93 99 Well Tests; Gray clay,stiff,dry 99 - Was a pumping test performed? i'No O Yes c= > .by whom? Yield-_--._gpm with ft•drawdown after T__lus. Yield _gpm with ,,_It.drawdown atter hrs. Yield -_,BP m with ft.drawdown after_ hrs. Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Water Level "—'— ---J Time Water Level Time Water Level Time Date of pumping test — Bailor test gpm with ft.drawdown after_hrs. Air tort 20 gpm with stem sot at 80 ft.for 1 hrs. — Date 10/13/23 Artesian flow_gpm Start Date 10113/23 Completed Dote 10/13/23 Temperature of water 51 °F Was a chemical analysis made? O Yes ENo WELL CONSTRUCTION Materials CERTIFICATION: used and I onst reported above actedand/or true sib eptresponsibility for knowledge and oft this well,and its compliance with all Washington well the ationconstruction standards. a f. Phythian Drilli_ ng�on' A° Arcadia Drilling Inc. l Driller O Trainee C7 PE—Print Address PO Box 1790 ~— Si taturc Cit ,State 'L,i Shelton,WA 98584 _r----- Licenso No. 2053 Contractor's IF TRAINEE:S onsor's License No. Date 10/13/23 Re istration No.ARCADDI098K1 Sponsor's Si nature ECY 050.1-20(Rev 09/18) If you need this document in an alternate format,please call the;Valor Resources Program at 360-407-61172. Persons with hearing lots 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: JON ZUFLUH (Logan Spear) Well Tag#: BPF061 Well Site Address: Bergeson Rd, Shelton Depth: 96' Date of Test: 10/17/2023 Pump Set: 80' Static: 34.3 TIME GPM LEVEL RECOVERY 1 Min 6.4 37.5 TIME LEVEL 2 Min 6.4 0.9 1 Min 49.5 3 Min 6.4 40.1 2 Min 46 4 Min 6.4 41 3 Min 43.9 5 Min 6.4 41.3 4 Min 42.5 6 Min 6.4 41.7 5 Min 41.5 7 Min 6.4 42 6 Min 40.9 8 Min 6.4 42.2 7 Min 40.5 9 Min 6.4 42.4 8 Min 40.1 10 Min 6.4 42.6 9 Min 39.9 15 Min 9.3 43.1 10 Min 39.8 20 Min 9.3 47.1 25 Min 11.5 47.7 30 Min 11.5 50.5 35 Min 14.2 51.2 40 Min 14.2 53.6 45 Min 14.2 54.1 50 Min 14.2 54.8 55 Min 14.2 55 1 Hr 14.2 55.2 yanguard..Labbratory V2635 Paikmont Lane SW,Suite A Olympia WA 98502 • v",TEM•n 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Lori cr ,C'.7 Yea r.::::. LLi2_Q_.IPM �O5'Qfl Type of Water System(check only one box) ❑Group A ❑Group B M Other Group A and Group B Systems—Provide from Water Facilities Inventory(WI): ID# System Name: Contact Person:Aroodia Drilling,Inc LA aq✓ Day Phone:(.369---).P6.3a95 Cell Phone: 0 ) z3f-1344/ _ Email: Evo.Phone:( ) Send results to:(Print full name,address and rip code or a-mall) arlefe4oreadladrirting,servIANa4mod;erowlladriWat.ca» - ...ggn Sir t _ •SAMPLE INFORMATION Sample collected by(name): Specific location where sample collected: Special instructions or comments: 927 C.North la Pf 621114 Type of Sample(select only one type of sample from types 1 through 5 below) —1.❑Routine Distribution.Sample(A/P) 2.(Si Repeat Sample(A/P) _ (from distribution system after unsat,routine) Chlorinated:Yes_ No K Unsatisfactory routine lab number: Chlorine Residual:Total. Free ._.-- .V 1 5___'I I__2,1212*. 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: SI I it / II , 2S Chlorinated:Yes No_'t_,_ ❑Triggered(NP) Chlorine Residual:Total _Free ❑Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) S ❑E.coil 0 Fecal Filtered Yes_No 5.M Sample Collected for Information Only: LAB USE ONLY DRINKING WATER REOUk.T•8.:; {,AB.USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory ❑E.coll present 0 E.coli absent Bacterial Density Results:Total Coliform <1.0 /100ml. E.coti <1.0_/100ml, Fecal Coliform_ __. 1100ml. I-IPC /1 ml. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0 pate me Rec I Lab Reference Nmnber Receipt Teh,pC: NethodCode: SM9223B Date Reported to DOH Lab Use Only: DOH Lab-Sample# ...z.„Ac 285-r)/0,5 i, Won K3J1119tetbdrvls end other pnErr000no,,4tleCowo doh w gosidtnnl�'keste 012Y(TDDIfYYcol7th).