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HomeMy WebLinkAboutWAT2026-00062 - WAT Application - 3/22/2026 WAT 2026 - 00062 MASON COUNTY a ge 415 N.6'h Sheet Shelton.WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services 13elfair: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: Christopher E Van Ackeren Date: 3-22-2026 Mailing Address: 60 SE Selles Drive, 98584 Phone: 541-913-0950 Parcel Number: 391021400000 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more % Building permit BLD2026-00259 connections) O Division of land: ❑ Individual water source(one connection), #of Parcels?__1 SPL X Well 0 Boundary line adjustment O 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 WEL2026-00009 Name of Water System: k �= - Water Facility Inventory(WFI) Number: X71-.)' (write"none"for two-party) I am the manager of this water system.The water system has been approved for 1 services.There are presently 7 connection(s)in use.This will be the connection. I. 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: —t-we' 'P � t. z t_ Picu r st$ O 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 7 /`t � Phone � 1 '?6 Signature of Water System Manager Date Tr ` 1,5-- This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Pagel of 2 Group B Water Systems _pçSatisfactory bacteriological test within last year(attach to application). Individual Water Well 'Water well report(attached to application). Depth ft. 8/13/2025 Well capacity Test(attached to application) gpm 2. 3bO 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. 9/1O/2O25 Satisfactory bacteriological test within last year(attach to application). 9/10/2025 Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection_NIA ❑ 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. ❑ Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). EH APPROVED Reviewer's Signatures: Environ. Health: Anderson 04/08/2026 Date 4/8/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT f DEPARTMENI OF Notice of Intent No. WE60574 ECOLOGY Unique Ecology Well 11)Tag No. BQC126 Type of Work: State of Washington iE Construction Site Well Name(if more than one well): ❑ Decommission c Original installation NOI No. Water Right Permit/Certificate No. Proposed Use. O Domestic 0 Industrial ❑Municipal Property Owner Name Christopher Van Ackeren O Dewatering ❑Irrigation O Test Well O Other Well Street Address Wellswood Way Construction Type: Method: J New well 0 Alteration O Driven O Jetted ❑Cable Tool City Shelton County Mason ❑Deepening O Other ❑Dug fJ Air- O Mud-Rotary Tax Parcel No. 31902-14-00000 Dimensions: Diameter of boring 6 in.,to 158 tl. Was a variance approved for this well? ❑Yes N No Depth of completed well 157 ft. If yes,what was the variance for? Construction Details: Wall Casing Litter Diameter From To "Thickness Steel PVC Welded Thread p O 6 in. 0 154 25 in. © 1 O Gl i O Location(see instructions on page 2): 3 WWM or O EWM ❑ 1 O in, — in. ❑ O ❑ O SE '/s-'/of the NE V.;Section_,,2 .. Township JL Range 3W ❑ l ❑ in. in. ❑ ❑ ❑ O ❑ I O in in. ❑ I ❑ O I O Latitude(Example:47.12345) 47.16430 N Longitude(Example:-120.12345) -123.01509W Perforations: ❑Yes ❑� No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size ofpertorations in.by-in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft.to-it.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 17 Yes 0 No O K-Packer Depth 151 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire-wrapped Model No. Diameter 5" Slot size.010 in.from 152 ft.to 157 ft. Brown silty sand,dry 0 4 Diameter_ Slot size_in.from _ft.to_Il. Light brown sandy clay,sticky 4 22 Light brown fine gravelly sand,clay binder 22 28 Sand/Filter pack:0 Yes I1 No Size of pack material in. Brown fine sand and gravel,clay bound,dense 28 35 Materials placed from ft.to.-__,ft. Brown fine to large sand and gravel,loose,moist 35 53 Surface Seal: ❑Yes ❑No To what depth? 18 ft. Gray boulder 53 54 Material used in seal Bentonite chips Gray fine to large silty sandy gravel 54 62 Did any strata contain unusable water? ❑Yes I7 No Type of water? Depth ofstrtta Gray fine to large round gravel,silt bound,dense 62 95 Method of sealing strata off Gray fine to coarse silty sand,tannins,wet 95 121 Gray fine to medium silty sand,some gravel, 121 Pump: Manufacturer's Name Type: woodchipS,tannins,wet 144 H.P._ Pump intake depth:_ft. Designed flow rate: gpm Gray fine to large sand and gravel,heaving,water 144 158 Water Levels: !-and-surface elevation above mean sea level 65 ft. Stick-up oftop of well casing 1_5 R.above ground surface Static water level 50 ft.below top of well casing Date 8/13/25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: \Vas a pumping test performed? O No ❑Yes by whom? Yield gpm with-ft.drawdown after his. Yield_gpm with_ft.drawdown after his. Yield_gpm with_ft.drawdown after_hrs. Recovery data(titme=zero when pump is tuned 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_ _,hrs. Air test 35 gpm with stem set at 80 ft.for 1 hrs. Date 8/13/25 Artesian flow gpm Temperature of water 51 °F Was a chemical analysis made? ❑Yes ❑No Start Date 8/13125 Completed Date 8/13/25 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. El Driller❑Trainee❑PE—Print ame Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098KI Date 8/13/25 ECY 050-1-20(Rev 09118) If you need this doewnent in an alternate fawns:,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons tvitlr a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Christopher Van Ackeren Well Tag#: BQC126 Site Address: 300 SE Wellswood Way, Shelton Depth: 157' Date of Test: 9110/25 Static: 47.8' Pump Set: 140' TIME GPM LEVEL RECOVERY I Min 5 48 TIME LEVEL 2 Min 5 48.3 1 Min 51 3 Min 5 48.5 2 Min 50 4 Min 5 48.5 3 Min 49.4 5 Min 5 48.5 4 Min 48 6 Min 5 48.5 5 Min 47.8 7 Min 5 48.5 8 Min 5 48.5 9 Min 5 48.5 10 Min 20 48.5 15 Min 20 50 20 Min 20 51.2 25 Min 20 51.8 30 Min 20 51.8 35 Min 20 51.9 40 Min 20 51.9 45 Min 20 52 50 Min 20 52 55 Min 20 52 1 Hr 20 52 1 Hr 10 Min 20 52 1 Hr 20 Min 20 52 Vanguard Laboratory 2635 Parkrnont Lane SW,Suite A Olympia WA 98502 360-967-7010, taco*ATU*Y COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 09110!2025 1 2 a O DAM Month Day Year —_ --l PM Type of Water System(check only one box) ❑Group A ❑Group 8 IN Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID#System Name: Christopher Van Ackeren 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 e-mail) arleta@arcadiadrifling.com AND)enn@arcadiadrlfing.com SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Special instructions or comments: BQC126-300 SE Wellswood Way.Shelton `Counts please Type of Sample(select only one type o{sample from types I through 5 below) 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP) Chlorinated:Yes_ No (from distribution system after unsat rouline) Unsatisfactory routine lab number. Chlorine Residual:Total,Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: $ I Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total Free_ ❑Assessment(NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E.col O Fecal Fluttered Yes_Nn_ 5.©Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and X}Satisfactory ❑Ecolii present 0 Eeoli absent Bacterial Density Results:Total Coliform <1.0 _/100m1. E.coli <1.CLji00mi. Fecal Coliform 1100m1. NPC 11 ml. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/Time eceived: t.at:Reference Number Receipt Temp C°: Method Code: L\1 { Date Reported to DOH ( Lab Use Only: DOH Lab-Sample# 285- COti rom#'3.1879(effunme 001;)-tl yna neat CO Oibka tunas arta{Eana6vafrennn,ne0100.5250107(1O07Th neT T51), T,ane c"ra pwucae ea se aoaiable al wa.ticn.aa�rhtiatiry'ux ar.