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HomeMy WebLinkAboutWAT2026-00017 - WAT Application - 2/18/2026 wATeYAV - 006 415 N.6th Street �° r �. Shelton,WA 93584 ` -11)13- 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: J✓St o,.-+ 4 le:"' ;e1-,.CL Date: //b)T/�5~ Mailing Address: 3`'i I I C. nfg6v.-t .i t-d Phone: 3( c 2.1-;(..\ (A-Lie ,war 5 8511344 Parcel Number: 3 ad Z 3-3r.aloe, Type of Water System Reason for Application ❑ Public/Community Water System (2 or more B Building permit he l;;G "O connections) O Division of land: Ind ividual water source(one connection), #of Parcels? SPL ell 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. ❑ 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 ge Water well report(attached to application). Depth 91 ft. 10/22/2025 Well capacity Test(attached to application) 25 gpm >400 gpd.10/29/2025 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). 11/06/2025 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) —I 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). EII APPROVED Reviewer's Signatures: Environ. Health: An&rsonO2""2026 Date 02/18/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 • WATER WELL REPORT DE T MEt'i T"' Notice of Intent No. WE61199 017) ECOLOGY Unique Ecology Well ID Tae No. BQC197 Type of Work: State of 1 a.,l-.ing-.on Site Well Name(if more than one well): C' Construction 0 Decommission Original installation N0I No. \A'aterRtghf Permit/Certificate No. Proposed Use: <a,Domestic 0 Industrial 0 Municipal 'Property Owner Name Justin Ragsdale O Dewatering 0 Irrigation O Test Well ❑`Otter -.— Well Street Address 3911 E Mason Lake.Rd Constructor Type: Method: E New well 0 Alteration O Driven p Jetted 0 Cable Tool City She County Mason O Deepening O Other O Dug Q Air- O Stud-Rotary Tax Parcel No. 32123-31-00000 Dimensions: Diameter oftoring 6 in„to 91 ft. Wasa variance approved for this.well? O Yes 0 No Depth'of completed well 91 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread li i 0 o in. 0 83 . .25 in. ? 1 0 t 0 Location(see instructions on page 2): @ WWM or D EWM 0 1 0 in, _____ _in. 0 I O 0 I 0 ' SE 'i,-1/4 of the SW Vi;Section 23 Township 21N Range 3W 1 O in. .in. 0 I 0 0 I 0 O in. _ _ in. ❑ `; ❑ ❑ I 0 Latitude(Example:47.12345) 47.29307 N Longitude(Example:-120.12345) -123.02565 W Perforations: 0 Yes 'No Type of perforator used of perforations Size of in.by Driller's.Log/Construction or Decommission Procedure Na. in. _ft.below eround'surfata Formation:Describe by color,character,size of material and structure,and the'kind and Perforated from ft,to nature of the material in each layer penetrated,with at least one entry for each change of Screens: tl Yes O No ©K-Packer ` > Depth 81 ti.. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5" Slot size.018 in.from 82 ft.to 87 ft. Brown silty sand,gravel 0 3 Diameter 5" Slot size.000 in,from 87 ft.to 91 ft. Brown siilbound sand,gravel,loose 3 l 26 Gray silty sand,gravel 26 34 Sand/Fitter pack:O Yes E No Size of pack material in. Brown silty sand,few gravels 34 53 Materials placed from ft.to ft. Brown coarse sandy silt 53 70 Surface Seal; 1 Yes .O No To what depth? 18 ft. Brown coarse gravelly sand,water 70 87 Material used in seal Bentonite chips Sift bound sand,gravel,dry .87 91 Did any strata contain unusable water? 0 Yes c No 'Type of water? Depth ofstrata Method of sealing strata off l Pump: Manufacturer's Name Type: H.P. Pump intake depth' ft. Designed flow rate: gpm - - Water Levels: Land-surface elevation above mean sea ravel 280 ft. Stick-up of top of well casing 1.5 ft.above ground.surface Static water level 18 It.below top of well casing Date 10/22/25 Artesian pressure lbs.per square inch Date ' Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ©No O Yes b by whom? 'Yield gtpn with ft.drawdown after hrs. Yield son with ft,drawdown after his • . gpm with-8.drawdown after hrs..Recovery data(time_zero when pump is tamed off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level —r Date of pimping test p Bailer test gpm with`ft.drawdown after_hrs. Air test 30 .gpm with stern set at 60 ft.for"1.5 hrs. Date 10/22/25 Artesian flow gpm Temperature,ofwwater 50. ''F Was a chemical analysis niadc? 0 Yes E No Stair Date 10/21/25 Completed Date 10/22125 • • 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 r Train PE—Pr i me James Johnson Drilling Company Arcadia Drilling Inc. Signature W,�,t(� �.... Address PO Box 1790 License No.. 479T City.State,Zip Shelton,WA 98584 • IF TRAINEE:S onsor's License No.2874 Contractor's Sponsor's-Stgnature Registration No.ARCADDI098K1 Date 10122/25 • • ECY 050-1.20(Rev 09/113) Ifyou need this doctnnertr in an alternate format,please coll the Water Resources Program at 360--/07.6572. Persons a it)r hearing loss can call 711 jar il'ashington Relay Service. Persons with a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer:Justin Ragsdale Well Tag#: BQC197 Site Address: 3911 E Mason Lake Rd, Shelton Depth: 91' Date of Test: 10/29/25 Static: 18' Pump Set: 80' TIME GPM LEVEL RECOVERY 1 Min 5.5 19.7 TIME LEVEL 2 Min 5.5 20.1 1 Min 21.2 3 Min 5.5 20.2 2 Min 19.2 4 Min 5.5 20.3 3 Min 18.2 5 Min 14 20.3 4 Min 18.1 6 Min 14 23.3 5 Min 18 7 Min 14 24 8 Min 14 24.1 9 Min 14 24.3 10 Min 25 24.4 15 Min 25 30 20 Min 25 30 25 Min 25 30.1 30 Min 25 30.1 35 Min 25 , 30.1 40 Min 25 30.1 45 Min 25 30.1 50 Min 25 30.1 55 Min 25 30.1 1 Hr 25 30.1 1 Hr 10 Min 25 30.1 Total Gallons Pumped: 1592 t'+rt,%N A p f..T-4�H.. ASK �_t l � /1 ��Si9�: izsa . 111111111.11, ieie 80411 St E.Yocon-Ira.WA 08404 'Mir COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected WO Orly Year Type of Water System(check only one box) (7\11 � �_ 0Group A 0 Group S Cliher-_ v - Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): System Name:j(� 4 c c Contact Person: Day Phot (j�,,, )'"1.acl?.i3T5 Cell Phone:( ) Email: Eve.Phone:( ) Send•csuitstp,:�Print full nee.add(�55 and zip code) i�W G1Y�t1 1 G�ci +lkt BC) • COm cte c rcacl'a �c�v�l t o �rld ne e awl _ - - SAMPLE INFORMATION Sample collected by(name): 5h d Specific location where sample col lad: Special instructions or comments: R,oc I �� qa Type of Sample tselact only ono type of sample from types f through 5 below) I..J Routine Distribution Sample(NP) 2.❑ Repeat Sample(A/Pi --.-•horn dintrlbutirm system alto'r11Seti nnlbl+el Chlorinated Yep No Unsatisfactory routine lab nurnher Chlorine Residual:Total Free ! l . 3 Ground Water Rule SWUM Somplu ! a Unsatisfactory routine weed date: I I 5 Chlorinated i'es_ tau LI Triggered DWI Chianne Residual.Total Free 0 Assessment (NP) 4 Surface orGW1 Raw Source Wata•r Sample lEnumeratontS I r E.cob ❑F�-cal +Morttl vtr No �°'. •:..•.�' i 5,r ,,mI:U:.:.6.>r*pd rnr Information Only: LAB USE ONLY DRINIUNG,WATER RESULTS LAB USE ONLY ! Unsatisfactory Total Conform Present and _ 5ailsFactary 0 E.co!i present 0 E.coli absent Bacterial Density Results:Total Coition '10pml. E.cah I700ml. FecalCotifonn„_ 11UUml, HPC. __..... _ ;1 ml. Replacement Sample Required: 0 TNTC 0 Sample too old i 0 Sample Volume 0 Damaged Container 0 __.. GaterVe Received: Lab Role once Number I . I- •- ._ _15.__._ Receipt Temp C": Method Code: Date ed o DOH Lob Use Only: DOH Lab.Semple# 089 "5,-)-P--k ).- --n, r1.11-31P ruflt?Uaa 05.71.ft On MIA Uas 6Min5tx)Na�t:e NMI 515VI:ITTUI)TIrvl:II. Tres pn06hxe;u!k.daert w ara41t00 alma Jill cA 0ne:MAtiaiyik,