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HomeMy WebLinkAboutWAT2026-00018 - WAT Application - 3/10/2026 (2) WAT f - MAS 415 N.6"'Street + ' 1x. Shelton,WA 98584 w t Shelton:360-427-9670,Ext.400 Public Health 81 Human Services Beltair'.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: 60U0n/lah /(A/rlt/T Date: t /Z PZ Mailing Address: 1Z/3 S YeL11 3* Ce 1/4 Phone: 360-6246/- Parcel Parcel Number: Z ZoZ 00/1 qe51.3/ Type of Water System Reason for Application O Public/Community Water System (2 or more Or Building permit l7D -0001 connections) O Division of land: lYr Individual water source (one connection), #of Parcels? SPL El" Well 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) 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. 0 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.of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Ei' Water well report(attached to application). Depth 2- 7 7 ft. 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. 181 Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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 ® --4 Part 3: Mason County Community Services Evaluation (staff use only) l Satisfactory Determination: This determination does not.address adequacy of the.distribution system,guarantee an adequate supply of water Indetinitely lnthe future,or guarantee:compliance with all applicable.WDQE 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 ❑ Unsatisfactory Determination: Applicant's water.supply does not appear adequate to meet the-,)1660 .0f.its intended use for the:following reason(s). . . iRANYVYM,6' •Reviewer's Signatures -' Environ. Health. Date 3/10726 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT �'?'' . DEPARTMENT OF Notice of Intent No. WE58960 ECOLOGY Unique Ecology Wall[D'l'agNo.,SQL 698 Typo ufWorkt State of Washington [J Cousin:olioo Site Well Nano(inflow than ono well): ❑ Decommission Original Installation NOI No. Water Right Pennit/Certificate No. Proposed Ulna 1.l Doinscilc O Industrial O Mnnlcipal Property Owner Name Lexar Homes Q Downlcring O Irrigation O Test Well O Other Well Street Address Xx SE Arcadia Rd Construction Typot Mctheili City Shelton County Mason l l Now well O Altemlion O Driven O Jailed ❑Cobbo Tool o Deepening O Oilier O Dug RI Ail, O Mud-Rotary Tax Parcel No, 22028-76-90011 Dimensions: Diameter of boring 6 in,,le 277 !t. Was a variance approved for this well? 0 Yes ®No Depth of completed well 277 4. If yes,what was the variance for? Constructlou Dotnllsf Nall Casing Liner Diutnerer From To Thickness Steel PVC Welded Thread PIO 6 In, +1.6 272 26 In, Ll I ❑ O I O Locution(see instructions on page 2): l WWM or O EWM ❑ I ❑ __In. — „__., _...ln. ❑ I ❑ O I O SG t/a-1A of the NE ii;Section 29 Township 20N Range 02 1 O I O In. —— -__ in. O I O O I O Latitude(Example:47.123<I5) 47,18567 O I O lit. __ , —. ._.__..in. ❑ I O O I O . Longitude(Example:-120,12345) -122.95439 Pcrfnrattails; ❑Yes 0 No Type of perforator used Driller'sLog/Cans:enctlonor Decommission Procotiure ' f No,of perforations_ Size of perforations—in.by__,ht' Formation;Describe by Dolor,diameter,size of material and structure,end Me kind and Peribraied from II,to_ft,below ground airline nature of the material in each layer penetrated,with at least ono entry for sorb change of Scrcenst Oil Yea O Na • CI K Packer b Depth 271 11. lnfonantioe,Use additional shoots if necessary, i I iv(anulhentrcr'sNmng Johnson MaterialFrom To Type Stainless Glee' Model No, Gravel,fill 0 2 Diameter 6 in, Slot size A10 in,4ma 272 (Ito 677 R. 2 2 Diameter, in. Slot size„^„__, in.(tu a-�--IL to T ft. Top soil Clay,sill,sand few rocks 3 7 Sand/Miter packs inYes CI No Sire of nook nwtedul in. Sand,gravel,silt,brown/soft 7 22 Materials placed front ft.In __n. Sand,silt,brown/soft 22 30 Sirfaue Seal] Cl Yes O No To what dopih? 20 ft, Sand,slit,tine,gray/soft 36 48 Material used in sent Bentonite Granular Clay,graylhard ' _ 49 88 Did any strata cannon namable water'? G Yee 0 No Sand,slit,little water,brown/soft 68 90 'faro aware?? Depth of strata 90 97 Method of sealing strata off Sand,slit,fine,gray/soft Sand,silt,line,gray/soft 97 112 Pomp'tvinannieturor'sName N/A Type: Sand,clay,gray/hard • 112 • 148 RP._- Pump Intake depth: R. Designed flow rote: gpm Sand,gravel,some clay,gray/hard 148 177 Water Levels! Lancl-aerface elevation above mean sea level___,ft, Sand,slit,clay,gray/hard 177 195 Slick-up of tap of well casing +1,6 ft.above ground surface Clay,gray/hard 195 212 SmIle avatar level 214 IL below tep of well easing Dote 3/20/2026 Sand,gravel,slit,some clay,gray/hard 212 226 Artesian pressure_ _lbs,per square inch Date Adnahan water is controlled by _.-,(cap,valve,are,) Sand,slit,gray/hard 226 246 Sand,silt,gravel,gray/hard 246 262 Well Torsi Sand,gravel,slit,gray/hard wb 252 277 Wes a pumping test performed? Ll No O Yes ==> by whoa:? Yield glue with II.II,drnwdown after _,__lure, Yield spin with II.drnwdown after„Itrs. Yield pm will: II.drnwdown alter_hrs. Recovery dale(dm=ma when pump is tented off—tenter level incnstred trout well lop to water level) Tirne Water Level Time Water Level Tiers Walor Level Date of pumping lost w Bailor lest spin with ft,drnwdown after._._lila, Air test 30 gpm with stein sot at 276 5,14 1 bre, Dee 3/20/2025 Maslen flow awe Temperature of water_,,,.°P Was a oliemteal analysis made? O Yes ©No Start Date 3/19/2026 Completed Date 9/20/2026 'WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and lls compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief, IA Driller❑Trainee O P6—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature (r, „_,,,- (, g _ Address 1102 NW State Avenue License No, 2263 City,State,Zip Chehalis,WA 98632 IF TRAINBE:Sponsor's License No. Contractor's Sponsor's Signature • RegistrtilionNe. MOERKSP072N6 Date 3/20/2025 ECY 050-1.20(Rev 1 I/I S) ifyou need this doctunenl In an allernafe formal,please call the Water Resources Program at 360.4!17.6872, Persons rind;llealilig lass and ott/I 7/1 for Washington Relay s&,Mica. Parsons 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 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 7177.14 216' 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' 2O 12 7369.15 216' 25 12 7429.15 216' 30 12 7489.15 216' 35 12 7549.15 216' 40 12 7609.15 216' 0 216' RECOVERY 1 2 3 SIGNATU ONS ND DRILLING Le.,ccuv- Vanguard Laboratory •i, ,: . 2635 Parkmont Lane SW -W' Olympia,WA 98502 360.967.7010 VANGUAlit1r, Report of Laboratory Analysis • LABORATORY Collected by: Moerke and Sons Matrix Drinking Water 360.748-3805 Laboratory ID:V250402-16 Sampling Address: Date Sampled;4/2/25 14:00 SE Arcadia Road Lot#1 Date Received:4/2/25 15:10 Shelton,WA 98584 Date Reported;4/4/2025 Sample ID: SE Arcadia Road Lot#1 Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.colt by SM 92238(IDEXX) Batch ID:V250402-16 Analyst:AF Coliform,Total Negative I 1 MPN/100 rnL 1 4/2/25 16:48 E.coil Negative - 1 I MPN/100 ml.. 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 Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 04/04/2025 DF:Dilution Factor 214` 47025x2017 S.;rwwas MCL:Maxbnutn Contaminant Level 1,;���� 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 I Office:360.967.7010 I testing@vanguardlaboratoty.com I www.vanguardlaboratory.com 1of1