HomeMy WebLinkAboutWAT2026-00030 - WAT Application - 2/9/2026 WAT_ 2026-00030 j
rtfAji .‘ ': M ON COUNTY FEB ?02�'5 N:6th Sheet
`"t " Shelton,WA 98584
i '1%,,,, ,‘' �,' . Shelton:360-427-9670,Ext.400
. Public Health ez Human,Services 61 elim9' gtExt.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part T.. 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/ Par el Identific ;on 9
Name of Applicant: y� ® n Date: R/(�0( (Mailing Address: cd 'NG�e �° 1 �-'hone: a (p —ae -629-1
Parcel Number: Lk a1 a,-- `�)-23 1 OO O
Type of Water System Reason for Appllicationp�,
XPublic/Community Water System(2 or more .12I('Building permit 0 OCy0U/-CCO 1
connections) 0 Division of land:
O Individual water source(one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
❑ Spring/surface water 0 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 See WEL2025-00115
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: (2\OO..n, U1)1°A\
Water Facility Inventory(WFI)Number: none (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(Le: 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
7:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2
•
Group B Water Systems •
•
El Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
•
al Water well report(attached to application). Depth 235 ft
IXI Well capacity Test(attached to application) 16.5 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. Satisfactory BacT by Thurston '
County EH 11/25/25 per
® Satisfactory bacteriological test within last year(attach to application), WEL2025-00115
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
Satisfactory Determination:: .: :...:..:' : `r: ..:-..
This'determination.does:not address adequacy of the:distribution systemL.guarantee.an adequate supply of.
water ilideffnitely In.the.futurk.or guarantee compliance with all applicable WDOE,viater resource regulations.>.. ..;
• Recoinmended.approval.indlcates requirements"of Sanitary Code,Title e;Chapter 6 68 040 Determination of
. Adequacy for•Bullding Permits are satisfied.::•Additional.Growth.Management requirem.ents.may.apply„ Chapter 'r
36.7OA RCb
:0:- Unsatisfacto .Determinatio.n`
• A licant'swatersup ly:dbes.riota p earado uate.toMeat`the,needsofitsIntehdeduse:forthe:folloyvin `
pp pp Y I?p. q
reason(s)} : .. :..
ryt4" ev ewer's S natures:..-:
. ...... ..:...
Environ. Health: Date •
This form may be scanned and available for public view at www.masoncountywa.uov
Page 2jof 2
RECEIVED
MAY 2 3. .2024
WATER WELL REPORT � `' DEPARTMENT Of Notice of Intent No. WE47518 WA State Depai'tmeilis
ECOLOGY of Ecology (5WRO)
Unique Ecology\Nell ID Tag No.BNV877
Type of Work:. State of Washington
Q:6:insruciion ,Site Well Name(if more than one well):.
O Decommission => Original installation N0t No, Water Right PermiUCertificatc No.
Pra solid Use: L 1 Domesiic 0 Industrial' :❑Municipal '' Property Owner Name Troy Johnson •
❑Dewatering O Irrigation 0 Test Weil 0 Other '
Weil Street Address 200E Miracle Heights Or,.
Construction Types method:
I7 New welt ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County,ht3S0
❑Deepening Q Other ❑Dog Gil Air- O Mud-Rotary Ta.Parcel No. 4212333-00000 ..
• Dimensions: Diameter of boring 6 in;io`240 ' ft Was a variance approved'for this well? D Yes l7.No
Depth oleompleted well 235 a.
[eyes,What was the variance for?
Construction Details:. Well
Casing.Liner Diameter From To Thickness Steel PVC Welded Thread
$ I O 6 .in. 0 235 .025 in. R I ❑ 17 1 O Location(see instructions on.page 2): DI W\YMorOEWM
O I ❑ in, is P I ❑ O1 O SW ''/r•Y.of the SW Ye,,Section 23 Township 21N Range 4W
O I O �in. -in. O I ❑ 0 1 0 Latitude(Example:4712345).47.287949 N
❑ I ❑ in. •in ❑ I 1:1p I ❑ xamp : ,
.
—
Longitude(Example:-120.12345)-123.161942 W
Perforations: QYes DNo Type of perfotator used Driller's Log/Construction or Decommission Procedure
No.otpsrtomations_ Size ofperforstions_in.by_in. formation Describe by color,character.size of material and structtue,'and the kind and
Perforated from!ft to_ft-below ground steface nature of the material in each layer penetrated,with at least one entry for each change of
' Screens: ❑Yes i7 No ❑[.packer b Depth_it. information. Die'additional sheets if necessary.
G Manufseturers Name Material From To
e Type Model No.
N Diameter Slotaizein.from _a.to_tt. Brown fine to medium sandy gravel,loose,dry 0 46
Diameter_ Slot Size—_in.Goth ft.to_fl. Brown fine to medium sand gravel,silt bound, 46
tight,dry . . 129
e sand/Filter pack:0 Yes O No Size of pack material_in Gray clay,stiff,dry 129 140'
o Materials placed from_ft to_S.
Black sharp gravelly gray clay,stiff,dry 140 144
i Mated�i used in seat' Bentonite Chips'Surface Seal: R.Yes O No 7o what depth? 19 fr. Brown fine to medium sandy gravel,brovmish 144
gray silt,binding,tight,dry 171
2 Did any strata contain unusable water? 0Yes DM;
3 Type orwaterl Depth ofstrata • ... Brown line sandy gravel,brown clay,binding 171
d Me'ihod of sealing strata off with organics;tight,dry . 179
Brown medium to coarse sandy gravel,tight,wet 179 1133
Pump:kfanulcturer`sNam Typsc Gray Silty clay,stiff,dry .183 165
e H.P. Pump intake depth:__ft. Designed flow rats:_gem Brown fine to medium sandy gravel,sharp,. 185
t. \Voter l ei els Land:surface elevation above meat sea le%'ei•327 i}. tight,dry 191
a- Sh4,up afros)of well easing _1.5 R above gonad SUS EGO. Gray.clay,stiff,dry 191 210
i Siatre water level '162 low top of well casing Date 619122
'Ariesran presnra lbs.per square:nth Date Brown fine sandy gravel,tight,there,dry .210' 223
c Artesian water is controlled by (eap,valve;arc.) Gray Clay with black sharp gravel,hard,'dry 223 227
Brown coarse sandy gravel,tight;water , .227 236'
o Welt Tests: Gray Gay,hard,dry 236 238
Was a punmptng lest perfoaned'7 l No •❑Yes ' by whom? •
Yield_gem u•iih�R.drawda,moner_hrs. Black sharp gravel,gray silt bound . 238 240'
u Yield_'gpm with'`ft.drawdotm alter- firs.• ,
Yield_gpm with_ft drawdown afcr_ins. .
I Reeorerydata(lirtw=zero?Shen pump is ruined off—.water level measured ram well
tip to water level)
3 Time Water t.evel Time Water Level Time Water Lev-el --'
•
•
u .
a
Dateorpuntping.test _
Bailer test_gpm with ft.drawdoyvri after_hrs. ...
Air sect 30 gpm with stem set at 22 ft.far_ hrs. Date 619122
Artesian f lod•:_Spm.
Temperature o&Water 52 ."F Woe achemicat analysis made? ❑Yes, D No Start Date 618/22 Completed Date 6/9/22 _
WELL•C NSTRUC1 QN CERTIFiCATIO\: ['constructed ondforaceept responsibility for construction of this well,and its compliance with all Washington wail
construction standards:Materials used and the information reported above are true to mybest knowledge tied belief.
)D Driller O Trainee O PE—.P�tli' e Roger Fhythlan. Drilling Company Arcadia.Drilling inc. .
•Signature �!/r lj` . Address PO Box 1790 .
;License No.2053. .7 City,State.Zip Shelton.WA 98584
IF TRAINEE:.Sponsor's Lic(nse No. Contractor's
•
Sponsor'SSignature Registration No.ARGADDi098K1. .__ Date 6/9/22
ECY a0-1,-20•(Rev 09]18):Oro geed this document lu an alternate format,please call the Water Resources;Program 01360e407-6372
Persons irid)hearing loss cal email 7l l for ti oslilogiotr Relay Service. Persars with a speech disability,cair call S77-833-63:11.
gICI-12u riuiri
£� DN .
Printed from Mason County D' i '
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Troy Johnson Well Tag#: BNV877
Site Address: 200 E Miracle Heights Dr,Shelton Depth: 235'
Date of Test:12/03/2025 Static: 162'
Pump Set:200'
TIME GPM LEVEL RECOVERY
1 Min 167 16.5 TIME LEVEL
2 Min 170.8 16.5 1 Min 175
3 Min 172.5 16.5 2 Min 172
4 Min 174 16.5 3 Min 171
5 Min 175 16.5 4 Min 169.8
6 Min 176 16.5 5 Min 168.5
7 Min 176.9 16.5 6 Min 167.5
8 Min 177.5 .16.5 7 Min 167
9 Min 177.9 16.5 8 Min 166.5
10 Min 178.2 16.5 9 Min 166
15 Min 180 16.5 10 Min 165.5
20 Min 181.5 16.5 11 Min 165
25 Min 182 16.5 12 Min 164.5
30 Min 182.1 16.5 13 Min 164
35 Min 182.2 16.5 14 Min 163.5
40 Min 183.3 16.5 15 Min 163
45 Min 182.4 16:5 16 Min 162.7
50 Min 182.5 16.5 17 Min 162.5
55 Min 182.6 16.5 18 Min 162.4
19 Min 162.3
Total Gallons Pumped: 907.5 20 Min 162.2
21 Min 162.1
22 Min 162
Pri ntedoff, 3
Mason
Printed from Mason County DrvIS