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HomeMy WebLinkAboutWAT2025-00231 - WAT Application - 2/5/2026 WAT U:�`3 - CCU ? I MASON COUNTY 415 N.6Street Shlton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health 8z 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 11/4/25 Name of Applicant: Matt and Kaida Wees Date: Mailing Address: 353 E Sunny Woods Rd W Phone: 360-561-3072 Parcel Number: 321163390082 Type of Water System Reason for Application 0 Public/Community Water System(2 or more a Building permitiiCtZZ5 -©1. .P connections) ❑ Division of land: la Individual water source(one connection), #of Parcels? SPL GI Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ 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. Cl 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 oft Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth qg ft. ER Well capacity Test(attached to application)_ 17 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 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. 51 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 o Part 3: Mason County Community Services Evaluation (staff use only) it 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: RAtktryniostwt Environ. Health: Date 2/5/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 oft WATER WELL REPORT _ DEPARTMENT OF Notice of Intent No. WE61237 ECOLOGY Unique Ecology Well ID Tag No. BRR 200 Type of Work: State of Washington ll Construction Site Well Name(if more than one well)' ❑ Decommission r Original installation NO!No. Water Right Permit/Certificate No. Proposed Use: LCDonseelio I7Industrial 0 Municipal Property Owner Name Mathew Weeks L7 Dewetering ❑irrigation ❑Test Well ❑Other Well Street Address 353 E Sunny Rd W Construction Type: Methodr Now well O Alteration El Driven 0 Jetted 0 Cable Tool City Shelton County Mason El Deepening 0 Other 0 Dug @1 Air" ❑Mud•Rolary Tax Parcel No. 321169.33-90082 Dimensions:Diameter of boring 6 in.,to 100 ft Was a variance approved for this well? ❑Yes ©No Depth ofeompteted well 99 8. Construction Delalhs Wall If yes,what was the variance for? Casing Liner Diameter Prom To Thickness Steel PVC Welded Thread HI 0 6 in, +1 94 .26 in. O I El ❑ I Cl Locution(see instructions on page 2): ll WWM or Cl EWM ❑ I ❑ in. _in. ❑ I Cl ❑ I ❑ SW °r Ye-r/a of the SW 'Al Section 16 Township 21N Range 03 ❑ I ❑ in. in. Lilo DIE] ❑ i 0 in, In ❑ i ❑ ❑ ❑ Latitude(Example:47.12345) 47.30250 Longitude(Example:-120.12345) -123.07801 Perfornttonst 0 Yes ❑e No Type ofperforalorused No.of perforations Size ofperfamtions_In.by®in. Driller's Log/Construellen or Decommission Procedure Perforated hom ft.to ft.below ground surface Formation:Descn'be by color,character,size ofmaterial end structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑a Yes ❑No Cl K-Packer Depth 93 8. information. Uso additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Stainless Steel Model No, Diameter 5 in. Slot size .018 in.from 94 ft.(0 99 g. Top soil 0 Diameter in. Slot size in,hom Ii.to It. Sand,gravel,some silt,brown/soft 1 20 Sand/Fllter pack:❑Yes ID No Size of pack material-in. Sand,gravel,sill,brown/soft 20 71 Materials placed ftem_,8.to 8, Sand,gravel,slit,brown/soft,wb 71 100 Surface Stab M Yes ❑No To what depth? 18 ft. Material used in seal Bentonite Granular Did any strata contain unusable water? ❑Yes 0 No Typo ofwater? Depth ofstrata Method of sealing strata off Pump: Manufacturer's Name N/A Type; A.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level Stick-up o flop of well casing +1 ft.aboveground surface Static water loot 57 ft.below top of well casing Date 10/10/2026 Artesian pressure lbs.per square inch Dale Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? NI No ❑Yes C14 by whom? Yield gpm with e Ii drawdown a fler hrs. Yield_gpm with_IL draw down after_hrs. Yield gpm with ft.drawdown after hrs. Recovery data(lime=zero when pump is honed off—water level measured from well top to water loyal) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test gpm with ft.drawdown after hrs. Air test 45 gpm wvilh stein set at 97 R.for 1 hrs, — Data 10110/2025 Artesian flow gpm _ Temperature of water 'F Was a chemical analysis made? ❑Yes ❑+ No Start Date 10/10/2025 Completed Date 10/10/2025 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 the information reported above are true to my best knowledge and belief. Q Driller O Trainee LI PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling mature r��M Address 1162 NW State Avenue License No. 2253 City,State,Zip Chehalis,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072NS Dale 10/13/2025 ECY050.1-20(Rev 11/18) Ifyou need this document in an alternate format,please call the Water Resources Program al 360407-6872. Persons Wilt!tearing loss can call 711 for 11'ashinglon Relay Service. Persons with a speech disability can call 877-833-6341 MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST MATHEW WEEKS 10/30/2025 WELL SITE ADDRESS: 353 E SUNNY RD W, SHELTON WA 98584 Pump Make & Model: 1HP 15 Pump Set At: 80' Sounder Make & Model: WATERLINE Make & Model: MASTER Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 7621.5 57' 1 18 7639.5 58' 2 18 7657.5 58' 3 18 7675.7 58' 4 18 7693.4 58' 5 18 7711.6 58' 6 18 7729.4 58' 7 18 7747.6 58' 8 17 7765.8 59' 9 17 7782.8 60' 10 17 7872.7 60' 15 17 7962.3 60' 20 17 8052.4 60' 25 17 8142.6 60' 30 17 8232.8 60' 35 17 8322.4 60' 40 17 8412.5 60' RECOVERY 0 60' 1 58' 2 57' SIGNATUR • ONS P AND DRILLING Vanguard Laboratory V2635Parkmont1:aue SW,Suite A .610npili WA 98502 gettog�ltD 360-967-7010 014021/PO4 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County O I ( /15 2 S Collected DAN ,AA WM Day 'Nat `Z. •60 0 pm MIX-5 An Type of War System(dledt only ono boo() ❑Group A ❑Group ❑other Group A and Group B Systems-Provide from Water Facilites inventory(WEI): ID# System Name: i Y la w4LvS Contact Person; AAt ho vv-t if1ac4-eA- .r r Day Phone:(3iio ) lie, -- ,m5 Cell Phone;( ) Email: Eve.Phone:( ) Send marts to:(Print M name,eddt(a end zip code a o-rna9) — ----- r=-srte-- ---- SAMPLE INFORMATION Sample collected by(name): S5-C__ Specific bcat)on where sample collected: Special Instructions or carmnenb: 353 6at 5G;n,nytLkz.c3s Re Wcst i ,l41tttcm, Wa- ciB L( i Type of Sample(select only one typo of sample horn types 1 through 5 below) 1.❑Routine DtstritwHon Sample(A/P) 2.❑ Repeat Sample(NP) Chlorinated:Yes yi No (ken dsbibulon system after onset.ratline) I Chlorine Residual:Total�Free Ur>satbladay marline tab number. 3.Ground WaterRuhr Source Sample — Unsatisfao(ory routine ooltact dale: 5 —______/ J Chlorinated:Yes Ne_ ❑Triggered(A/P) Chbdne Residual:TotaL__.Free__ I 0 Ass cement(A/P) 4. Surface et OW1 Raw Source Water Sample(Enumerator)) S I ❑E cod 0 Fecal r77dea yes_No 5.❑son*Coaocled IOC lnrormiUon Only. LAB USE ONLY DRINKING::WATER RESULTS LAB USE ONLY ❑Unsatiafactoty Total Cold=Present and 14 Satisfactory ' ❑E.cog present 0 E.coli absent Bacterial Density Results:Total Conform /100m1. E.coll____Jinor7d. FecalCotlorm 1100ml. HPC 11 mt. I i Replacement Sample Required: ❑TNTC ❑sampte too ok) ❑ Semple Volume ❑Damaged Container E Lab rtenonce Number r7213 R471.. i{ ab .y251a3i—IV 5 Race! T 2 Temp `t Method SM pq'123.6 0.Cato Reputed to DONLab Use Only. I DOH Lib-Sa naa 285- 03 (10 bon fpm Ai...XI-NI •If ro rend Iipli.lanh n*mho bx..t..rebea£iam(Toanmi 71 I). I I Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 360-967-7010 ningf.FD Nitrate/Nitrite Analysis Report Date Collected:(MM/D0/YT) 10 M30 /25 System Group Type:(circle one.) A B Ot':r: Water System ID Number: System Name: Lab Number/Sample Number: 2 6 6J0 3 i 1 0 County: If\Q603) Sample Location 353 Cast• 6uNrv..1 Wadi IZd Wt it Source Number(s) (List all sources if blended or compos(ted) SW-WO O A , Ws._. �1 c c i Sample Purpose(check appropriate box) Date Received: (MM/DD/YY) 1 A/32 5 ❑ RC—Routine/Compliance(Satisfies monitoring requirements.) Date Analyzed: (MM/DD/YY) ljj3 �2 5 ❑ C—Confirmation(Confirmation of chemical result.)' Date Reported; (MM/DD/Ye) • 11 I—Investigative(Does not satisfy monitoring requirements.) COMM NTS: Q C--Other(Specify—does not satisfy monitoring requirements.) \�l�f 7.,G 10 I Sample Composition(Check appropriate box.) Sample Type(Check one.) ❑Pre-tratment/Untreated(Raw) gi S—Single Source ' O Post-f reatment(Finished) ❑ B—Blended(list source numbers in Source Numbers'field) DUrikntiwn or Other ❑ C—Composite(List source numbers in"Source Numbers"field) Sample Collected by:(name) ,1egt _ ❑ D—Distribution Sample Phone Number: 3tvo {� Send Report to: Bill to:(Client name.) MnexicA._ .ir Sov't 5 - rs/br ,Snore, Mot lJt() St'akc . Avt., tllo2. Jli. Je At)? C.Int..(nOA,s (u. q t , Gnat vs (AJ 53z Analytical Results Data Exceeds M MCL? Method/ DOH U Contaminant Qualifier Results MRL , SDRL Trigger MCL Units (R If Yes) Initials 0020 Nitrate-N 1.39 0,5 U.S 5.0 10.0 mg/I. Hach 10206 NOTES *Confirmation:Include the original lab number,sample number,and collection date of original sample in either comment section, --No trigger value for combined nitrate plus nitrite. Data Qualifier;A symbol or letter to denote additional information about the result, • DOH#:Department assigned contaminant number. Exceeds MCL(Maximum Contaminant Level):Marked if the contaminant amount exceeds the Ma under chapters 246-290 and 246- 291 WAC. If you have questions about this result,please contact the department's drinking water regional office in your area, METHOD/INITIALS:Analytical method used/initials of the analyst that performed the analysis. mg/L:milligrams per liter or parts per million. MRL(Method Reporting Limit):The lowest quantifiable concentration of a contaminant. SDRL(State Detection Reporting Limit):The minimum reportable detection of a contaminant as established by the department. Trigger:The department's drinking water response level,Systems with contaminants detected at concentrations at or above this level may be required to take additional samples or monitor more frequently. LAB COMMENTS Revised December 2021