HomeMy WebLinkAboutWAT2026-00048 - WAT Application - 4/1/2026 WAT 2026 - 00048
MASON COUNTY
415 N.61 Street
Shelton,WA 98584
Public Health & Human Services Belfan:360-427 4467 Ext.400
R 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 Identificat .[-[p,kcviSr_)v)
Name of Applicant: �` wc1 Date:
Mailing Address: ?31 v`' / , �- ',C 4 Phone: 3 �` 2.Q 2`—
Parcel Number: 13 J—c
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more IS Building permit BLD2026-00190
connections) O Division of land:
,..3 Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water O
❑ Other(explain) 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)
❑ 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.
❑ 1 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
O Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
N Water well report(attached to application). Depth 155 ft ft 2/10/2026
gl Well capacity Test(attached to application) 20 gpm >800 gpd.2/18/2026
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);- --2/18/202-6
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)
X 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-
36:70ARC1N
Unsatisfactory Determination
Applicants water supply does not;.appear adequate to meet the needs of its intended use for the following
reason(s).:
LH APPROVED Reviewer's Signatures
:.. J
�I1/2026
Environ. Health: Anderson 04/0U203b Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT De A 1\l nl °- Notice of Intent No. WE61801
ECOLOGY Unique Ecology Well ID Tag No. BRG677
Type of Worst State of ash ngton
l Construction Site Well Name(if more than one well):
0 Decommission Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: L Domestic O industrial O Municipal Property Owner Name Jeff Hokenson
❑Dewatering O Irrigation O Test well =!Other Well Street Address 520 E Cottonwood Dr
Construction Type: Method: Cite Grapeview County Mason
E New well ❑Alteration O Driven O Jetted O Cable Tool
O Deepening ❑Other O Dug 11 Air- O Mud-Rotary Tax Parcel No. 22128-31-00000
Dimensions: Diameter of boring 6 in.,to 156 ft. Was a variance approved for this well? ❑Yes [' No
Depth of completed well 155 ft.
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
Cm I C 6 in. 0 151 .25 in. . 1 O J I C Location(see instructions on page 2): Li WWM or D EWNI
D I G in. _ in. ❑ I ❑ O i D NE !/,-t/,of the SW Va;Section 28 Township 21 N Range 2W
O l C __in. _ in. Dl C O I C
D I C in. _ in. ❑ ! D D i o Latitude(Example:47.12345) 47.27917 N
Longitude(Example:-120.12345) -122.94130
Perforations O Yes R No Type of perforator used
No of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
Perforated from ft.to_ft.below ground surface Formation:Describe by color,character.size of material and structure,and the kind and
nature of the material in each layer penetrated.with at least one entry for each change of
Screens: r'Yes O No R K-Packer Depth 149 L information. Use additional sheets if necessary.
Manufacturers Name Alloy Machine Works Material From To
Type Stainless slatted Model No.
Diameter 5" Slot size.030 in.from 150 ft.to 155 ft, Reddish brown silty sand,gravel 0 2
Diameter Slot size in.from _ft.to ft. Brown slitbound sand,gravel 2 25
Brown claybound line sand 25 48
Sand/Filter pack.❑Yes 9 No Size of park material_in.
_ Brown claybound fine sand,few gravels 48 61
Materials placed from_ft.to ft.
Brown silty medium sand with gravel 61 90
Surface Seal: I Yes ❑No To what depth? 18 ft- Brown silty fine sand,few gravels 90 102
Material used in seal Bentonite Chips
Did any strata contain unusable water? O Yes KI No Gray claybound sand,gravel 102 110
Type of water? Depth of strata Brown silty sand,gravel,loose,wet 110 141
Method of sealing strata off Black gravel,sand,water 141 156
Pump: Manufacturer's Name Type:
H.P._ Pump intake depth:_ft. Designed flow rate._gpm
Water Levels: Land-surface elevation above mean sea level 245 ft.
Stick-up of top of well casing, 1_5 ft.above ground surface
Static water love( 90 R.below top of well casing Date 2/10/26
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? No O Yes . 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 \Vater Level Time \Vater Level Time Water Level
Date of pumping test
Bailer test—epm with_ft.drawdown after_bra.}
Air test 30 gpm with stem set at.120 ft.for 1 hrs. Date 2110/26
Artesian floss'_gpm
Temperature of water 50 "F Was a chemical analysis made? 0 Yes No Start Date 2/9/26 Completed Date 2/10/26
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.
r-j
D Driller Cam!Tr i i&D PE—FE—Prjasr1me James Johnson Drilling Company Arcadia Drilling Inc.
Signature i Y .'ti, Address PO Box 1790
License l<lo. 3479T City.State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No.287// Contractor's
Sponsor's Signature ci "'-. `T a Registration No.ARCADDI098K1 Date 2/10/26
ECY 050-1-20(Rev 09118) !fyou need this document in an alternate formal,please call the Rater Resources Program at 360-407-6872.
Persons stint!tearing loss can call 711 for R ashingion Re/at'Service. Persons with a speech disability can call 877-833-6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer:Jeff Hokenson Well Tag#: BRG677
Site Address: 520 E Cottonwood Dr, Grapeview Depth: 155'
Date of Test: 2/18/26 Static: 91.5'
Pump Set: 140'
TIME GPM LEVEL RECOVERY
1 Min 6 92 TIME LEVEL
2 Min 6 92 1 Min 91.5'
3 Min 6 92
4 Min 6 92
5 Min 14 92
6 Min 14 93.5
7 Min 14 93.5
8 Min 14 93.5
9 Min 14 93.5
10 Min 20 93.9
15 Min 20 94.7
2OMin. -.. ..2ff..._ . ... --94:7 --...-...
25 Min 20 94.7
30 Min 20 94.7
35 Min 20 94.7
40 Min 20 94.7
45 Min 20 94.7
50 Min 20 94.7
55 Min 20 94.7
1 Hr 20 94.7
1 Hr 10 Min 20 94.7
Total Gallons Pumped: 1514 Gallons
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
r�xtr�U,•ten 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
02/18/2026 J e 0 I!AM Mason
Nana Day Year
❑PM
Type of Water System(check only one box)
❑Group A O Group B Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID# .......—
System Name: Jeff HokenSon
Contact Person:Arcadia Drilling,Inc
Day Phone:(360 )426-3395 Cell Phone:( )
Email: Eve.Phone:( )
Send results to:(Print full name,address and zip code or email)
adeta@arcadiaddiling,com AND lenn@arcadiadrllling.com
SAMPLE INF0RMATI0N
Sample collected by(name):Max
Specific location where sample collected: Special instructions or comments:
BRG677-520 E Cottonwood Dr.Grapeview Counts pleas e
Type of Sample(select only one type of sample from types 1.through 5 below)
1.❑Routine Distribution Sample(NP) 2.❑ Repeat Sample(AIP)
Chlorinated:Yes No (from distribution system after unsat.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S I I
Chlorinated:Yes Na
❑Triggered(AIP) Chlorine Residual:Total__.Free_
❑Assessment(AIP)
4. Surface or GWI Raw Source Water Sample(Enumeration)
❑E.coif ❑Fecal FRered Yes_No_
5.( I Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colifonn Present and 21 Satisfactory
❑E coli present O Ecof absent
Bacterial Density Results:Total Coliform <1.0 I100m1. Eccli <1.0 1100m1.
Fecal Coliform /100ml. HPC /1 ml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume O Damaged Container ❑
Me Rgcely Lab Refe ence Nuutbar _
Receipt Tern
c':2_ Method Code:S M9223 B
Date Reported to DOH 2/23/2026 Lab Use Only:
DOH LatrSample#
285-O7-' -221
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