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HomeMy WebLinkAboutWAT2026-00016 - WAT Application - 2/3/2026 WAT 2026-00016 eoli,46, . MASON COUNTY 041 415 N.WA Street 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: Dewhill Homes LLC Date: 117/2026 Mailing Address: 1830 E Brockdale Rd Shelton WA Ste: 360-490-1353 Parcel Number: 222333290050 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 12 Building permit connections) 0 Division of land: ® Individual water source(one connection), #of Parcels? SPL ® Well 0 Boundary line adjustment O Spring/surface water 0 Other(explain) O 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) 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 M Water well report(attached to application). Depth 272 ft. l23 Well capacity Test (attached to application) 6-12 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. El 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) X 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: clYkib-1/11\16t)44- 2/3/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT Ato DEPARTMENT of Notice of Intent No. WE59230 -- .. ECOLOGY Unique •Ecology Well ID Tag No. BQC120 Type of Work: State of Washington Site Well Name(if more than one well) CI Construction 0 Decommission r� Original installation NOl No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Lesley Kenyon 0 Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address E Mason Lake Dr W Construction Type: Method: O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Grapeview County Mason 0 Deepening 0 Other 0 Dug ©Air- 0 Mud-Rotary Tax Parcel No. 22233-32-90050 Dimensions: Diameter of boring 6 in,,to 280 ft. Was a variance approved for this well? O Yes CI No Depth of completed well 278 ft. -- — If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 1l I 0 6 in. 0 273 .25 in. IA I 0 O I 0 Location(see instructions on page 2): ©WWM or 0 EWM O I 0 in. — in. 0 1 0 0 I 0 NW Y.-%of the SW ''A;Section 39 Township 22N Range 2W ❑ I ❑ in. to ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.35226 N ❑ 1 ❑ in. — — in. ❑ 1 ❑ ❑ 1 ❑ Longitude(Example:-120.12345) -122.94849 W Perforations: 0 Yes ®No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations_in.by in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated front ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes 0 No Ii]K-Packer r) Depth 272 8. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works__ Material From To Type Wire-wrapped Model No. Diameter 5" Slot size.010 in.from 273 ft.to 278 ft. Brown fine to large silty sand and gravel,loose, 0 Diameter Slot size in.from ft.to ft. till,dry 8 Gray fine sand gravel,silt bound,tight,dry, 8 Sand/Filter pack 0 Yes 183 No Size of pack material M. hardpan 25 Materials placed from ft.to ft. Brown fine to medium silty sand and gravel, 25 Surface Seal: H7 Yes 0 No To what depth? 19 R. loose,till,some cobbles 75 Material used in seal Bentonite chips Did any strata contain unusable water? 0 Yes O No Brown fine sand,multi-colored fine to medium 75 Type of water? Depth of strata gravel 90 Grayish brown fine to medium sand and gravel, 90 Method of sealing strata off silt bound,tight 126 Pump: Manufacturer's Name Type: Fine to medium silty sand,multi-colored gravel, 126 H.P. Pump intake depth' ft. Designed flow rate: gpm loose,cobbles 143 Water Levels: Land-surface elevation above mean sea level 350 ft. Brown fine to medium silty sandy gravel,sharp, 143 Stick-up of top of well casing 2 ft.above ground surface loose 165 Static water level 196 ft.below top of well casing Date 7/9/25 Gray fine to medium silty round gravel,hard 165 193 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Dark brown clayey fine gravel,peat __193 _ 199 Gray fine to medium sand and gravel,silt bound, 199 Well Tests: hard 219 Was a pumping test performed? 8)No 0 Yes C-> by whom? Yield gpm with ft.drawdown after hrs. Brown fine to medium sand and gravel,silt binder 219 Yield gpm with ft.drawdown after hrs. moist 225 Yield gpm with ft.drawdown after hrs. Brown fine to medium silty sand and gravel, 225 Recovery data(time=zero when pump is turned off--water level measured from well loose,moist 249 top to water level) Brown fine to medium sand multi-colored gravel, 249 Time Water Level Time Water Level Time Water Level loose,heaving,water bearing 280 Date of pumping test Railer test gpm with_ft.drawdown after hrs.1 Air test 30 gpm with stem set at 260 ft.for I hrs. h. Date 7/9/25 Artesian flow gpm _ Temperature of water 51 'F Was a chemical analysis made? ❑Yes ®No Start Date 7/7/25 Completed Date 7/9/25 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. 0 Driller 0 Trainee 0 PE—Print a Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No,ARCADDI098K1 Date 7/9/25 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 ca11877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Lesley Kenyon Well Tag#: BQC120 Site Address: E Mason Lake Dr W, Grapeview Depth: 278' Date of Test: 7/23/25 Static: 198.7' Pump Set: 260' TIME GPM LEVEL RECOVERY 1 Min 6 200.3 TIME LEVEL 2 Min 6 201.4 1 Min 199.7 3 Min 6 201.5 2 Min 199.1 4 Min 6 201.55 3 Min 198.9 5 Min 10 201.6 4 Min 198.9 6 Min 10 202.5 5 Min 198.9 7 Min 10 202.9 8 Min 10 203 9 Min 10 203.1 10 Min 12 203.1 15 Min 12 204.1 20 Min 12 204.1 25 Min 12 204.2 30 Min 12 204.2 35 Min 12 204.2 40 Min 12 204.2 45 Min 12 204.2 50 Min 12 204.25 55 Min 12 204.25 1 Hr 12 204.25 1 Hr 10 Min 12 204.3 Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 I *ax gt`PD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 07123/2025 1 2 0 om PM vonth lay Year Type of Water System(check only one box) ❑Group A ❑Group B ®Other Group A and Group B Systems-Provide from Water Facilities Inventory(WEI). ID# ._._._...__. System Name: Lesley Kenyon Contact Person:Arcadia Drilling,Inc ' Day Phone (360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results tv(Flint full name,address and zip code or e-ma:'I) ar:eta@arcadiadriihng.com ANDjenn@arcadadrAng.corm1 SAMPLE INFORMATION Sample collected by(name):Shad Specific location where sample collected: Special instructions or comments. DQC920-E Mason Lake Dr W,Grapeview Type of Sample(select only one type of sample from types 1 through 5 below) I.❑Routine Distribution Sample(NP) 2 0 Repeat Sample(NP) Chlo nafed'Yes No (from disidbuion system after unsat,rout net Unsatisfactory routine lab number. Chlorine Residual:Total Free__�.. 3 Ground Water Rule Source Sample Unsatisfactory routine collect date: S l 1 Chlorinated:Yes.. No 0 Triggered(A/P) Chlorine Residual:Total--_........Free_......__.... ❑Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) S 0 E.cols ❑Fecal r;imi Yes_4c _ 5.IN Sande Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and 14 Satisfactory ❑E.coli present ❑E.coti absent Bacterial Density Results:Total Coliforrn /100ml. E.coll /100ml. Fecal Coliform.............__.._........__.........._/100ml. HPC—__—..__..._._..._...._/1 ml. Replacement Sample Required: 0 TNTC 0 Sample too old 0 Sample Volume 0 Damaged Container 0......._....__..� — Da ttin}ve R eire3 /.. Lab Reference Number Receipt Temp C'. Method Code. lei (Sn c 223 Date Reportec to DCC Lao Use Only- ' DOH Lab-Saralee 285-72321 SOSk.vr,ri31,3,9 ieffecMe,"a'1?I.ff xx tfti<:,e :i':a^attarative bwwt an KO..5 ?127 crOCi'v m# This Bret eeitl hate av&iitar a,ono*5th wit govvt5nkr5waa,