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HomeMy WebLinkAboutWAT2026-00044 - WAT Application - 3/16/2026 WAT 2026-00044 A° * N Cell TY 415 N.6thStreet Shelton,WA 98584 Shelton:360-427-9670,Ext.400 1 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: Bartle, Trinity Date: 3/16/26 Mailing Address: 2303 93rd Ave SW Tumwater,WA 98512 Phone: 360-359-4520 Parcel Number: 32024-21-90060 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more V1 Building permit BLD2026-00142 connections) ❑ Division of land: RI Individual water source(one connection), #of Parcels? SPL Well O Boundary line adjustment O Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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) ❑ 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 EA Water well report(attached to application). Depth 75 ft. >400 IRI Well capacity Test(attached to application) 15 gpm qpd. 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. 2g 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) 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 36.70ARCW. ' 0 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: Environ. Health: Date 3/16/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT ,,.,,,7721 DEPARTMENT O: Notice of Intent No. WE61318 ;7' ECOLOGY Unique Ecology Well ID Tag No. BRG675 Type of Work: :4P State of M ashington r Construction Site Well Name(if more than one well): 0 Decommission a Original installation NOENo. Water Right Permit/Certificate No, Proposed Use: ri l Domestic 0 Industrial ❑Municipal Property Owner Name Agnes Sumalbaq 0 Dewatering C Irrigation 0 Test Well 0 Other Well Street Address 4356 E Agate Rd Construction Type: Method: City Shelton County Mason E New well i i Alteration J Driven 0 Jetted 0 Cable Tool 0 Deepening O Other 0 Dug 1E Air- 0 Mud-Rotary Tax Parcel No, 32024-21-90060 Dimensions: Diameter of boring 6 in.,to 77 ft. Was a variance approved for this well? ❑" Yes O No Depth of completed well 75 ft. Wall yes,what was the variance for? Salt water and septic setbacks Construction Details: Casing Liner Diameter From To Thickness Steel PVC Welded Thread • I 0 6 in. 0 70 •25 in. 2 I 0 E I 0 Location(see instructions on page 2): G WWM or 0 EWM ❑. I 0 in. itt. 0 I 0 0 1 0 SE !/.-'of the NW ''A;Section 24 Township 20N Range 3W ❑ I 0 in. _ in. n I 0 0 ' 0 Latitude(Example:47.12345) 47.20947 N O I0 D in. _ in. ❑ I ❑ 010 Longitude(Example:-120.12345) -123,00329 W Perforations: O Yes G 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 from ft.to-ft.below ground surface nature of the material in each layer penetrated,with•at.least one entry for each change of Screens: El Yes O No [K-Packer (==> Depth 68 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No, Diameter 5_ Slot size.010 in.from 70 ft.to 75 ft, Brown silty sand,gravel 0 9 Diameter_ Slot size in.from ft.to_ft. Gray silty sand,gravel 9 _ 22 Brown slltbound sand,gravel 22 31 Sand/Filter pack:O Yes ❑+ No Size of pack material in. Gray siltbound sand,gravel 31 53• Materials placed from ft.to ft. Gray sand,few gravels,water 53 75 Surface Seal: E Yes 0 No To what depth? 32 ft. Brown sand,water 75 77 Material used in seal Bentonite Chips Did any strata contain unusable water? D Yes r+No Type of water? Depth of strata _ Method of sealing strata off - Pump: Manufacturer's Name Type: H.P. Pump intake depth: ft. Designed flow rate: gptn Water Levels: Land-surface elevation above mean sea level 10 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level ft.below top of well casing Date Artesian pressure 1/2 lbs.per square inch Date 2/4/26 Artesian water is controlled by Weld on flange(cap,valve,etc.) Well Tests: Was a pumping test performed? CI No O Yes t=t, by whom? Yield gpm with ft.drawdown after_hrs. Yield gpm with_ft.drawdown after hrs.'Yield gpm with ft,drawdown after hrs. Recovery data(time.=zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test gpm with—ft.drawdown after_his. Air test 15 gpm with stem set at 40 ft.for 1 hrs. .- Date 2/4/26 Artesian now 1/4 upm _ Temperature of water 50 °F Was a chemical analysis made? 0 Yes E No Start Date 2/3/26 Completed Date 2/4/26 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. ❑Driller T e 0 PE i Name James Johnson Drilling Company Arcadia Drilling Inc. Signature _. Address PO Box 1790 License o. 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 2/4/26 ECY 050-1-20(Rev 09/18) Ifyot need this doctwrent in an alternate format,please call the Rater Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer:Agnes Sumalbag Well Tag#: BRG675 Site Address: 4356 E Agate Rd, Shelton Depth: 75' Date of Test: 2/9/26 Static: Flowing Pump Set: 60' TIME GPM LEVEL RECOVERY 1 Min 15 6 TIME LEVEL 2 Min 15 12.7 1 Min 30.2 3 Min 15 18.4 2 Min 22.8 4 Min 15 24 3 Min 14.3 5 Min 15 28 4 Min 6 6 Min 15 30.3 5 Min 2.7 7 Min 15 31.2 6 Min Flowing 8 Min 15 32.5 9 Min 15 32.9 10 Min 15 33 15 Min 15 34.5 20 Min 15 35.2 25 Min 15 36.2 30 Min 15 36.5 35 Min 15 36.5 40 Min 15 36.5 45 Min 15 36.5 50 Min 15 36.5 55 Min 15 36.5 1 Hr 15 36.5 1 Hr 10 Min 15 36.5 Total Gallons Pumped: 1050 Gallons , ' . "mow_I 6 T--- .vv-- -.,,. - . Mt A.t4 AGE 1.=.4 E NT' ` :;., ..a^ t R OR!L 1r u', 15'18 Shit St E.Intor o,WA S O4 I OLU R A T RIA AN LY I Date Sample Celled Time Sample County Collected awl*, Day Yee' rType of Water System(check only one box) O Croup A n Group B 1 Other,_,.�....,� ... �._, _ . Group A and Group B,Systems—Provide from Water Facilities Inventory(WFI):_ ID# _ System Name; Contact Person: Day Phone:{31, •)412,i.' s1 Cell Phone:( ) Email: Eve.Phone:(.. ) • Seed resfdls to ' rtnt kiilnarne.address end p d7de) S 4 M Tea 0 Sample cattecter]by(name): t y r S ecific lotion wham earn le cote ted: i Special instructions or comments:. P Typo of mple(seleaonly One type of-sample from types 1 through 5 Wass) i 0 Routine Dastribaation Sample(+ 'P) 2.0 Repeat Sample(AlP) them distttedon ny3:eta=;Ster zrssot,rc em) Chlorinated:Fors N© .. tlatsatrsfaciory tontine lab number: Chlorine Residual:Total_..,,_Free;.,,,m a,Ground Water Refs 'out wrz:aloinple__ ( Unsatisfactory+routine collect date; I I a , Chlorinated:Y4s..____.. Nu._.„ 0 Ingge ad(AlP) l Chlorine Res€dual:To€al.. .....F»_... 0 Assessment (A)P1 _. __ _,,.. ._._ ___,,... 4.Surface or OWl Raw Source Water Sample(Enurneratiam t s i I I E.ortter' rr�r ,sza .� too.,. Crslecled;Information ors Ont, _� LAB use ONLY 1 WBWATER G[3LT LAB USE ONLY ( Unsatisfactory Total Caiirt n Present andSatacfssry 0 E:ooti present 0 Ecr fs aosent , Bacterial Density Results:Toad Conform__w....,._.,,_ .._PIMA E ft,,. ,_J100mL ( i Fecal Califon_ ._ —,�. ODml HPC.... ii ml, Replacement Sample Required 0 TNTC 0 Sample too old 0 Santo Volume O Damaged Container 0._,_,. _,,.,,_ "—. ____ Lab Reference Number Receipt Tamp C': Method Code: , I Da DOH tats Use Coup. DOW Leetnpte 089 41.171. (p i t _�., `.. P.WfCn,„,h,,540:..•,re 06 r e& ₹sime?e,rn iwar,eke i*u'tue WJ,...u5.(Y.1:T ODDITY ratite