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HomeMy WebLinkAboutWAT2026-00069 - WAT Application - 4/7/2026 WAT 2026-00069 A C SON�T 415 N.6`t'Street MA COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,Community Health Elma:360-482-5269,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 t @ 1s�..(•r Date: 3� /��S Name on Applicant: �ilV'�.. �v "4L Mailing Address: (in . Phone: Parcel Number: - 006 3t� Type of Water System / Reason for Application ❑ Public/Community Water System (2 or more li7J Building permit connections) ❑ Division of land: lindividual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water ❑ 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) ❑ 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. JAEH Forms'.Drinking Water Revised 4/4/2018 Individual Water Well (Water well report(attached to application). Depth 160 ft. riWell capacity Test(attached to application) 4.5-20 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 1415 166__22_ Water use or limitation recorded................................... N/A_____N/A Yes Well Drilled ............................................................... Date Individual Spring/Surface Water O WDOE permit(attach to application) O 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 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 36.70A RCW. 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:. 4/7/26 Environ. Health: Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 WATER WELL REPORT DEPAitTMMr OF Notice of Intent No. WE69013 * ECO LO GIIV Unique Ecology Well ID Tag No, BQC046 Typo ofWorkt State of Washington iN Constructiou Site Well Name(if more than one well): O. Deconunfssiou r OriglualinstallnttonNOiNo.. Water Right Pennit/CertificatoNo. Proposed Use: i Domestic, 0 Industrial ❑Municipal Property Owner Nance VM,gc,�r WdMygr U Downtoring 0 Irrigatk ue L7 Test Well 13 Other,._.._ ._,._.._.. Well Street Address 1955 E Agate Rd _,__ .,..,,,, Construction Types MethodsShelton___..._ County IINewwall UAlteration 0Driven 0felted 0 Cobb eTool City --w-- O Deopenitg 0 Other 0 Dug fel Air- O Mud-Rotary Tax Parcel No. 32011-13-00030 Dimensions Dlnntetarofboring Qin.,to 160 ft: Was.a variance approved for this well? 13Yes CI No Depth of completed well 1160 ft. Constructtott))otaflst Wall If yes,what was the variance fbr? Casing Liner Ohmmeter From To Thickness Stool PVC Welded Thread dal 1 0 6 In: 0 1. ... ,26 In. ® I U L I I O Location(see Instructions on page 2), 11 WWM or❑BWM o i © _In._In. _ In, CI I E3 13 I 13 g .y,-/4 of the i"4;Section 11 Township QL Mango, ( DID _ in, __ ,,-., .,_..in. DI 0 0 I ULatitude(Example:47.12345) 47.2386 N 0 I 0 ,.,_,..,.In, , ,. _in. Cl I 0 1 i IJ (B P _. a�_.. t _- Longitude(Example:-120.12345) -123.01864W Perforatlous: CI Yes iii No Typo of arforator used No.ofporforatious Size ofperforations—in.by___In. I>ripertsLerConstruafionai Decommission Procedure perforated front_____11.Ut- _,11,below ground surface lt cantles:Dmsoe a by color,ehametor,size ofntateriat and stiudturo,saddle kind and nature of lira material in cools layerpanot oted,with atleast cite entry for seals ohango of Screens: (D Yes D No M Wacker Depth 152 ft. infannniton.hoc additional shoots If necessary, M Manufacturer's Name Alloy machine works _ Material Prom Tb Typo Wire-wrapPed Model No. Dintuotor 6" Slot sizo c4_,,,,,�12 ,.In.lion 163 1t.ta,166_ ft. Grayish brown silty clay 0 6 o Dimnetcr,, ,'_ slot size.o,,nth its,from its_it.to,jL n, Gray fine silty sandy ravel clay binder 8 30 a -^— Brown One gravel,fine to coarse silt sand,moist 30 42. • nd/pilter packi 0 Yes IDNo Size of pack material-in. pre silt fine send moist 42 46 Sn hiatcrtals placed front,,,,, ._ft.to_,.-,.,_..ft: Gray slit fine ravel) sand,moist 45 47 Surface Scots [e7 Yes n No To what dop6t?,Z„,,,,,R. Brownish ra sand clfl eat 47 48 C Ivinterial used in scat Betonite chip S. Did mly olrota contnia umtsublo water? D Yes 10 Na Ora Mo sill sand t:la 48 63 c Qra fine sift sand clay binder 63 61 Typaofivatee2 •, ,,_,,.,,,,•._w,_.,._..,,., Doptitofetrnla Method ofseating strata off Gray tine silty ravel) sand,we ps,loose 61 77 Gray line to medium silt sand and ravel,moist 77 Pump:Manufacturer's Nano -- _ Typo: ,..,,.-,.-.„,,,_,_-. silt binder 86 H.P. Pmnp Intake depth.,,,,,,,__,ft. Dosigncd flow rate:__,,,spat Gray fine to sand ravell cla 86 89 Water Levelst Land.'urfhort olavation above meats sea level i6i ft. Gray fine slily sand and gravel,silt bound,moist 89 103 Slick up aftop ofwall casing._L.._It.above groundattrface Gray slily clay 103 1'21 Stoke water(oval 114 fl.below lop ofwellcooing Date 3118126 Gray fine to medium silty sand ravel,toose Wet 121 — 126 Maslen pressuro_lbs per square inch Dote Artesian water Is controlled by,,,_„__,_„_„__-,.,(cap,valvo,ono,) Fine to medium multi-colored.silly sand ravel 128 water bearing 137 wanTesrs: tine to medium lavender gray silty ravel,tt hit, 137 Woos pumping test porfonned? Cl No Cl Yes by whom? 163 Yield-gpntwith ft.drawdown after—his. water bearin Yield. __gpm with`_,a.drawdown after—lam, Yield ,,__gpm.wtat,,,,r,ft.drawdown after,.,,,••„tics. Recovery data(times zero when pump is turned off—water levelmeasured from well top to water'lavol) Thus Water Level Time Water Level Tinto Water Level o Dato ofpmuping roar: eDepartm lit - Sailor test gpntwith,._,,,,ft.dntwdownafter Ins. of Air toot 311�opmwitlt stem cot at 140 a.for his. Data .113 8126 Artesian flow—glen Temperature of water 1,.,,.°P Wits a chemical analysis made? ❑Yes B1 No Start Date 3/17/ Completed Date 3„1826 WELL CONS.'I'RUCUON CHwrwICATION: I constructed and/or accept responsibility for construction of this wall,and its compliance with all Washington well consttttotion.standards.Materials used and the information reported above are true to my best knowledge and belief. t- Q Driller ID Trainee D PB—Print Na c Cory Johnson Drilling Company Arcadia Drilling inc. Signature_________________________________________________ Address PO Box 1790 License No.3441T City,State Zip Shelton,WA 98584 _ r'___. n �t2 Contractor's S atrso's 3iB. as nsor's Litsa ✓a. f Y Registration No.ARCADi7109ti1C1 Date 3118128 _, ECY 050.1.20(Rev 09/18) /'you need this document in rat alternale fbrprat,please call the lVaterResources Program at 360.407.6872. Persons with hearing loss crux call 711 for FYashhrgion Relay Service. Persons with aspeech dlsabilftpcarreall877-833-6311. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Wendy Widmyer Well Tag#: BQC046 Site Address: 1958 E Agate Rd, Shelton Depth: 160' Date of Test: 3127125 Static: 109.7 Pump Set: 140' TIME GPM LEVEL RECOVERY 1 Min 4.5 110 TIME LEVEL 2 Min 4.5 110 1 Min 109.9 3 Min 4.5 110 2 Min 109.9 4 Min 4.5 110.1 3 Min 109.9 5 Min 13 110.1 6 Min 13 110.6 7 Min 13 110.5 8 Min 13 110.5 9 Min 13 110.5 10 Min 20 110.5 15 Min 20 110.8 20 Min 20 110.8 25 Min 20 110.8 30 Min 20 110.85 35 Min 20 110.85 40 Min 20 110.85 45 Min 20 110.85 50 Min 20 110.85 55 Min 20 110.85 1 Hr 20 110.85 1 Hr 10 Min 20 110.85 Total Gallons Pumped: 1283 Thurston County Env}ronmental health 412 Lilly Rd NE ptympier WA 98506 btu 3nt3867 263 + DLIIORM B1TR11 AlALYI DaNa sample taailsctad. 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II Fecal Col ml Jl1lGml nemoocal _,.Jl(UMn. • f Motho 92238LSh19222D paces dvee � g lJ SM 2f6R 0 Ent ertt$. 3•I t DisanditneAnd ,r tfGileRspo . 080