HomeMy WebLinkAboutWAT2025-00250 - WAT Application - 1/9/2026 1 WA'F 2025-00250 _
MASON COUNTY 415 N.6a'Street
Shelton,WA 91O84
aP Shelton:360-427-9670,Ext.400
Public Health & Human Services Beltair: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: �Q(-{l�w i[V� t�l AIO Date: I (J
Mailing Address: -\ e lJ-l-,f�yn t ;<1►5 -� 1 Phone: "L,r,t�
Parcel Number: 12.i 2 g�1(D "'Q) ()c ee 2_
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more It Building permit
connections) O Division of land:
Individual water source (one connection), #of Parcels? SPL
Well O Boundary line adjustment
O Spring/surface water ❑ Other(explain)
❑ 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)
❑ 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 Reviscd 05/08/2024 Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
El Water well report(attached to application). Depth ft.
15 >400 d,
® Well capacity Test(attached to application)_ —,gpm gp
The well driller often performs well capacity tests awe 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)
O 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)
• 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:
St1Lt--/L Date 1/9/26
Environ. Health:
This form may be scanned and available for public view at www.masoncountywa.Qov
Page'_01 2
WATER WELL REPORT :t» DEPARTMENT Of Notice of Intent No. WE45093
— - ECOLOGY unique Ecology Well ID Tag No. BNX171
Type of Work: State of Washington —
Ill Construction Site Well Name(if more than one well):
O Decommission r..-.* Original installation NOt No. Water Right Nand/Certificate No.
Proposed Use: DJ Domestic O Industrial O Municipal Property Owner Name Samantha&Jerry King
O Dewatering O Irrigation ❑Test Well O Other
Well Street Address 71 E Lloyd Ln
Construction Type: Method:
®New well ❑Alteration ❑Driven O Jetted ❑Cable Tool City Shelton County Mason
❑Deepening O Other _.._...____ ❑Dug Gil Air- ❑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 0 No
Depth of completed well 137 ft.
if yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
N I ❑ 6 in. 0 133 0.25 in. RIO I ❑ i I ❑ Location(sec instructions on page 2): E9 W\VM or❑EWM •
❑ I ❑ in. _ _ in. ❑ I ❑ O I O SW Y.-10.•of the SW Y,;Section_ 28 Township 21N Range 2W
❑ I ❑ in, — in. ❑ I ❑ ❑ i ❑
• I O in. in. ❑ I ❑ O I O Latitude(Example:47.12345) 47.276134
-i Longitude(Example:-120.12345) -122.946984
L Perforations: ❑Yes iii No Type of perforator used
8. No.ofperforations_ Size of perforations in by in. Driller's Log/Construction or Decommission Procedure
Os 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
ed Screens: 3)Yes ❑No O K-Packer r�^l' Depth 131 p. information. Use additional sheets if necessary.
4lanutacttrer's Name Alloy Machine Works
in Type Stainless Slotted Model No. Material From To
Diameter 5 Slot size.016 in.from 132 ft.to 137 ii Brown medium sand and gravel,loose 0 15
C Diameter- Slot size in from ft.to ft. Brown silty sand and gravel,tight 15 50
0
C Sand/Filter pack:O Yes Cl No Size of pack material in. Brown medium sand 50 56
O
Materials placed from_............_..ft,to ft.
Brown medium sand,wet 56 74
Gray silty clay 74 76
Surface Seal; �T Yes ❑No To what depth'? 18 ft.o Brown medium sand,wet 76 93
o Material used in seal Bentonite Chips
`+- Gray fine sand and silt 93 101
C Did any wain contain unusable water? ❑Yes E7 No
r- Type of water? Depth of strata Brown silty sand and gravel,wet 101 112
o
Method of sealing strata off Brown clay 112 114
c Multicolored gravel brown,fine to medium sand, 114
C Pump: Manufacturer's Name Type loose,water 137
O H:P. Pump intake depth; ft. Designed flow rate: gpm —
C Water Levels: Land-surface elevation above mean sea level 200 ft.
Stick-up of top of well casing 1.5 ft.above ground surface
ekt
t Static water level 76 ft.below top of well casing Date 11-3-21
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
C
O
s- Well Tests:
c.
O Was a pumping test performed? M No ❑Yes EL-4> by whom?
Yield gpm with ft.drawdown after hrs. - --v t"- (^ r" t\,7 � .
Yield gpm with___ft.drawdown after hrs_ '� . ., . 1 -.•..,i.A
0z Yield_._ __gpm with ft.drawdown after his. �,,.
N Recovery data(tune a,zero when pump is turned off-water level measured front well
o top to water level) JAN 0,. L 1
-. Tinre. Water Level Time Water Level Time Water Level
ii ....- ,r1: . e r)n i.,:ri t.
.:-.7 1
W Date of pumping test
C Baiter test gpm with ft.drawdown after hrs.
Air test 25 gpm with stem set at 120 ft.for 1 hrs. - Date 11-3-21
C Artesian flow gpm '
al
E Temperature ot'water 50 e F Was a chemical analysis made? ❑Yes 1 No Start Date 11-3-21 Completed Date 11-3-21
L
ci WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
of construction standards.Materials used and the information reported above are true to my best knowledge and belief.
n
t D Driller❑Trainee❑PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc.
~ Signature Address PO Box 1790
License No.287410" City,State,Kip Shelton,WA 98584
I:F TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADD1098K1 Date 11-3-21
ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability'can ea11877-833.6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584 BNX171
Customer:
Samantha& Jerry King Well Tag #:
Phone: 360-463-2245
Depth: 137'
Well Site Address: 71 E Lloyd Lane, Shelton
Pump Set: 127'
Date of Test: 11/912021
Static: 75.2'
RECOVERY
TIME GPM MEM TIME LEVEL
1 Min 12 78.7 1 Min 76.3
2 Min 9 78.7
78.6 2 Min 75.6
3 Min 9 3 Min 75.2
4 Min 9 78.5
5 Min 'anill
6 Min 9 78.4
7 Min 9 78.5
8 Min 9 Will
9 Min 9 78.5
10 Min 9 78.4
15 Min 9 EMI
20 Min 9 78,8
25 Min 9 78.8
30
Min alliMil 78.8
35 Min NM 79.8
40 Min Illailli 80.5
45 Min Mai 80.5
50 Min ® 80.5
INEISIM80.5
1 Hr � 80.6
1 Hr 10 Min alleni 80.7
Vanguard Laboratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
=, rrrv.Va0 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
(. Ob. ' a Au M C, SCV1
Mara, Day Year t
Type of Water System(check only one box) �
O Group A O Group B ®Dther__ .SL1L—
Group A and Group B Systems—Provide from Water Facilities Inventory(WFl):
ID#
System Name: y t' )t- 1`1'" * �--
Contact Persor rca�ia Drilling,taw". x'17
Day Phone,4360-44-26-3S11--- Phone:( )
~Email: Eve.Phone:( )
Send results to:(Pent full name,address and zip code or a mall)
S E AMPORMATION
Sample collected by(name):
a
Specific Ioton where sample ccoltected: Special instructions or comments:
t ' tit,`� C,Ck. 1 '
Type of Sample(select only one type of sample from types 1 through 5 below)
1,O Routine Distribution Sample(A/P) 2.O Repeat Sample(AM)
(from distribution system after unsat routine)
Chlorinated:Yes No
Unsatisfactory routine lab number:
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample Unsatisfactory+routine collect date:
IS I 1 I /
Chlorinated:Yes No_,
O Triggered(A/P) Chlorine Residual:Total Free
❑Assessment(NP)
4 Surface or GWI Raw Source Water Sample(Enumeration) ISI
❑E coil ❑Fecal Leered Yea_No
5.[Il Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and R Satisfactory
❑E.coli present O E.coli absent
Bacterial Density Results:Total Coliform<1.0 1100mt. E.coli <1.0 /100mi.
Fecal Coliform /100m1, HPC 11 mt.
Replacement Sample Required: O TNTC O Sample too old
❑ Sample Volume O Damaged Container O
DaterTime eired lab Reference Number
( / z— . �1t�7.-&°1 allePe ' 5*
Receipt C . Method Code:
Date Reported to DOH Lab Use Only.
DOH Lab-Sampierf
285- O/10-b
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