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HomeMy WebLinkAboutWAT2026-00018 - WAT Application - 3/10/2026 { WAT �t-),.�) `t {MASON COUNTY 415, A Street Shelton,VVA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services Bel fair:360-275-4467,Lat.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 (") /Zr'IZIC' Name of Applicant: {}(,llll�lin(,(�� !`j(Ji /R,�G?� Date: Mailing Address: /Z/3 �S' Ye(_/ J7- re nlntjl'u/,l✓4 Phone: 36o-62p-(apse. Parcel Number: Z Z 0.1 F70 00/1 ye513) Type of Water System Reason for Application o Public/Community Water System (2 or more iY Building permit 6IG O) Lt -00O l connections) ❑ Division of land: I{ Individual water source (one connection), #of Parcels? SPL 0' 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 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) 0 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 1:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of2 Group B Water Systems o Satisfactory bacteriological test within last year(attach to application). Individual Water Well Of Water well report(attached to application). Depth Z 7 7 ft. d Well capacity Test(attached to application) 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. ® 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 noi address adequacy of the distrlbutlon system,guarantee adequate.supply of water indefinitely in.the future,or guarantee:compliance with all applicable WDOE.water•resource regulations. Recommended approval indicates requirements of Sanitary Ggde,`title 6,Chapter 668.040 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 � 3110/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 • DEPARTMENT OF NoticeoflntentNo. WE68960 WATER WELL REPORT t,- ECOLOGY Unique Ecology Wall ID Tag No. BQL 008 'typo of Work: State of Washlnt{ton Il Construction Site Wall Namo(if more than ono well): O Decommission Original laskdlatlot NOt No. Water Right Permit/Cortifloate No. Proposed Unr EC Domestic 0 ledustriel 0 Ivhtnielpol Property Owner Name Lexar Homes 0 Dow:der:no 0 Irrigation 0 Test Well 0 Other Well Street Address xx SE Arcadia Rd Construction Typet Methadl City Shelton County Mason ©Now wolf 0 Alteration 0 Driven 0 Jetted 0 Cable Tool CI Deepening 0 Other 0 Dug NJ Air- El wild-Rolury Tax Parcel No, 22028-76-90011 Dimensions: Diameter of boring 0 in.,to 277 ff. Was a variance approved for this tvell7 0 Yes C1 No Depth of completed well 277 ft. If yes,what was the variance for? construction Details; Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread DIU e hi. +1.6 272 .26 in. © i ❑ O I fa Locution(see instructions on page 2): El WWM or O EWM O I 0 In. ___ In. ❑ I 0 0 I 0 SE Va-N oldie NE '''A;;Section 29 Township 20N Range 02 O I O in, —in. ❑ I 0 0 I 0❑ i ❑ in. in, ❑ i El Q I ❑ Latitude(Example:47.12345) 47,10587 v — _._. Longitude(Example:-120.12345) -122.95439 Perforations; 0 Yes 0 N Typo of perforator used , D1'1110r s Log/Construction or Decommission Procedure No,ofparfc:atlons_ Size of perforations in.by_ h:• Forme lion;Desedbo by color,ehnrnolor,elan ofumteriol and structure,end the kind and Perfbrofed from^I.to ft,below ground surface nature oftha materiel in each layer penetrated,with et least ono catty fur each change of Screeust D Yes 0 No d it.Paaker . Depth 271 R, information.Use additional sheets if necessary, Ivvtonufhcuurcr'oNarne Johnson Material Prom To Typo Stainless Steal Model No. Gravel,fill 0 2 Dinmotcr 6 In. Slot size .018 in,item 212 it.to 277 R. 2 3 Diameter in. Slot size___- in.thee-ft.toIi. Top soli Clay,silt,sand,few rooks 3 7 SnndQrllim peeler 0 Yea Eli No Size of parknnitrnel-tn, Sand,gravel,silt,brown/soft 7 22 Materials placed from_R.to-R. Sand,9111,brown/soft 22 36 Surface Cool, fa]Yes ❑No To whet depth? 20 ft Send,slit,tine,gray/soft 38 49 Matednl mad hi coat Bentonite Granular Clay,gray/hard 49 88 Did any strata contain uomnble water'? 0 Yee O No y — Sand,silt,little water,brown/soft 68 90 Tyne of water? Depth of shuts Sand,slit,flne,gray/soft 90 97 ivlotinotl of sealing strata off Sand,slit,tine,gray/soft i 97 112 Pomp: Mnnudreluror'sName N/A Typo; Sand,cly,gray/hard ' 112 ' 148 [h P. _ _ Pump Intake depth: R. Designed flow rote: gpm Sand,gravel,some clay,gray/hard 148 177 !Voter Levels: la nd-surloco elevation above mean see level-ft. Sand,slit,clay,gray/hard 177 195 Stick-up of top of well casing +1.6 8.nhovo wood surface Clay,gray/hard 195 212 static waferlovol 214 11.below top of well casing Date 3/20/2028 Sand,gravel,silt,some Maslen pressure__ _Iba,per square inch Onto y,gray/hard 212 226 _ Artesian water to controlled by (cup,valve,eta,) Sand,silt,gray/hard 225 246 _ SandLsllt,gravolLgray/hard 245 262 Well Tcstst Sand,gravel,silt,gray/hard,wb 252 277 Wes n pumping lost performed? O No 0 Yes r=: by whom? Yield gpm with`11.drnwdown niter ,_•_Ins, Yield gpm with a.drnwdown fakir_In, -told gpm withT R.drnwdown after,hrs. _ Itocoveuy date(ttmo=zero when pimp is turned off—water lava measured from well top to wider level) Time Water Lowi Time Wntar Level Tiara Water Level — Onto of pumping test — pallor acs! spin with it.drnwdown after—tee. Air lost 30 gpm with stem sot al 276 ft.l'or 1 bro. Date 3/20/2025 Artesian flow gpm Tompomluro of water P Was a chemical analysis made? 0 Yos EN No Start Date 3/19/2025 Completed Date 3/20/2026 '4YELi,CONSTRUCTION CERTIFICATION: I:entrusted and/or accept responsibility for construction of this well,and its compliance wills all Washington well construction standards.Materials used and the Information reported above are true to my beat knowledge and belief, III Driller 0 Trainee O PE—Print Name Chris Jones DrillingConspany Moerke 8,Sons Pump and Drilling mature —— 1 ,.„-.--- Address 1102 NW State Avenue •_, License No, 2263 City,State,Zip Chehalis,WA 98632 1P TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature &Re IstrntioteNo, MOERKSP072N6 Date 3/20/2025 BCY 050-1.20(Rev 11/18) ,(!'you treed tills&seamen/In an alrereate formal,please call the fYaierResour•ces Program al 360-407.6872. Persons with hearing loss can call 711 for IPaslringlan Relay Service. Persons with cc,speech dlsahlllly can call 877-833.6341. MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST • LEXAR HOMES 4/2/2026 WELL SITE ADDRESS: SE ARCADIA RD LOT# 1 Pump Make& Model: 1.5 HP 10 GPM Pump Set At: 260' Sounder Make & Model: Make& Model: MASTER Measured In: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 12 7129.14 214' 400 GAL.TOTALIZATION 1 12 7141.15 215' 2 12 7153.14 215' 3 12 7165.15 216' 4 12 717T14 216' 5 12 7189.16 216' 6 12 7201.14 216' 7 12 7213.15 216' 8 12 7225.14 216' 9 12 7237.14 216' 10 12 7249.16 216' 15 12 7309.15 216' 20 12 7369.15 216' 25 12 7429.15 216' 30 12 7489A5 216' 35 12 7549.15 216' 40 12 7609.15 216' 0 216' RECOVERY 1 2 3 SIGNATU 0NS ND DRILLING 1 Le ccur HADyNkts Vanguard Laboratory r` .t ` 2635 Parkmont Lane SW ii' ::' �t rl Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis • LABORATORY Collected by: • Mocrke and Sons Matrix Drinking Water 360.748-3805 • Laboratory ID:V250402-16 Sampling Address: Date Sampled:4/2125 14:00 SE Arcadia Road Lot l/1 Date Received:4/2/25 15:10 Shelton,WA 98584 Date Reported:4/4/2025 Sample ID: SE Arcadia Road Lot#1 I 1 Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.colt by SM 9223B(IDEXX) Batch ID:V250402-16 Analyst;AF Coliform,Total Negative l 1 MPN/100 mL 1 4/2/25 16:48 E.call Negative 1 I MPN/100 nil. 1 4/2/25 16:48 Nitrate by Hach Method 10206 Batch ID:V250402-16 Analyst:KS Nitrate(as N) ND 0.50 10.00 mg/L 1 4/2/25 17:00 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/04/2025 n/a:not applicable SDRL:State Detention Reporting Limit Approved by Tori Johnson,Operations Manager on 04/04/2025 DF:Dilution Factor '4"r 7a25r2417 MCL:Maximum Contaminant Level 7� ' &ccat:ouen Lsnoruronv Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory If you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 Office:360.967.7010 I testingt't�dvanguardiaboratory.com www.vanguardlaboratory.com loft