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Home My WebLink AboutWAT2026-00056 - WAT Application - 3/12/2026 WAT 2026-00056 MASON COUNTY 415 N.6'h Street E, Shelton..WA 98584 Public Health & Human Service Shelton:360-427-4467,Ext.400 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 on Applicant: LLA u_,i_ `h I . !� Date: _K __ Mailing Address: �; j �, - i ':1 � U� Phone: ( (D Parcel Number: I , c -- ' j('iy� Type of Water System Reason for Application Public/Community Water System (2 or more ❑ Building permit . connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well O ounda line adjustment ❑ Spring/surface water Other(explain) /`J LL. 9 / ❑ 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 t r Name of Water System: It 111 16 I flr ir `_) )J1;L. Water Facility Inventory (WFI) Numbe,: 13Df E (write"none"for two-party) ❑ 1 am the manager of this water system. The water system has been approved for services.There are presently L connection(s) in use. This will be the s. 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 Bailey Shinn Phone 3608011012 Signature of Water System Manag o�n A--,� Date 03/13/2026 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 WATER WELL REPORT a� • DEPARTMENT OF Notice of Intent No. WE61996 ECOLOGY Unique Ecology Well ID Tag No. BRL 686 Type of Work: State of Washington 17 Construction Site Well Name(if more than one well): ❑ Decommission . Original installation NO!No. Water Right Permit(Certificate No. Proposed Use: l7 Domestic ❑Industrial ❑Municipal Property Owner Name Michael Young O Dewatering O Irrigation ❑Test Well ❑Other Well Street Address 90 E Quail Hill Rd Construction Type: Method: ❑O New well ❑Alteration ❑Driven O Jetted ❑Cable Tool City Belfair County Mason ❑Deepening ❑Other ❑Dug ll Air- ❑Mud-Rotary Tax Parcel No. 12209-34-90090 Dimensions:Diameter of boring 6 in.,to 100 ft. Was a variance approved for this well? ❑Yes 0 No Depth ofcompleted well 99 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread tI I O 6 in. +1 94 .25 in. O 1 O ❑ I ❑ Location(see instructions on page 2): l 1 WWM or 0 EWM ❑ 1 ❑ in. — — in. ❑ ❑ 0 ❑ SE ''/s-%,of the SW %;Section 09 Township 22N Range 01 ❑ l ❑ in. in. ❑ O ❑ I ❑ ❑ 1 O in in ❑ O ❑ I ❑ Latitude(Example:47.12345) 47.40526 Longitude(Example:-120.12345) -122.81443 Perforations: ❑Yes I1 No Type of perforator used No. Driller's Log/Construction or Decommission Procedure Per ofperforations ns Size o groperfund hr•by u' 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: ❑O Yes ❑No ❑O K-Packer > Depth 93 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Stainless Steel Model No. Diameter 5 in. Slot size .018 in.from 94 ft.to 99 ft. Top Soil 0 1 Diameter in. Slot size in.from_ft.to ft. Sand,gravel,some silt,brown/soft 1 8 Sand,very little,gravel,brown/soft 8 32 Sand/Filter pack:❑Yes O No Size of pack material_in. Clay,brown/hard 32 37 Materials placed from_ft.to_ft. Sand,gravel,silt,some clay,silt,brown/soft 37 50 Surface Seal: ❑Yes O No To what depth? 16 ft. Material used in seal Bentonite Chips Clay,brown/hard 50 53 Did any strata contain unusable water? ❑Yes l l No Sand, ravel,silt,some clay,brown/soft 53 12 Type ofwater? Depth of strata Clay,silt,some sand and gravel,brown/hard 72 78 Method of sealing strata off Clay,gray/hard 78 86 Clay,silt,sand,some gravel, gray/soft 86 90 Pump: Manufacturer's Name N/A Type: Sand,coarse,silt,some gravel,gray/soft,wb 90 100 H.P. Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing.._.±L ft.above ground surface Static water level 47 ft.below top of well casing Date 2/4/2026 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? IN No O Yes . by whom? Yield_gpm with_ft.drawdown after_hrs. Yield gpm with_ft.drawdown after ills. Yield gpm with—ft.drawdown after lus. Recovery data(time=zero when pump is turned of£—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 75 gpm with stem set at 97 ft.for 1 ]vs. Date 2/4/2026 Artesian flow gpm Temperature of water-°F Was a chemical analysis made? O Yes ❑O No Start Date 2/03/2026 Completed Date 2/04/2026 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. O Driller❑Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature Address 1162 NW State Avenue License No. 2253 City,State,Zip Chehalis,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072N5 Date 2/04/2026 s� s == ECY 050?l-20(Rev 11/18) Ifyotsneed this document.in qn alterr�ate format,please call the Water Resources Program a: tr4i772\/ e`t'sat t [re tng ors ¢alt Cal/711 for�Vks fir tan Relay Service. Persons with a speech disability can call 8 833- . 7. 't 111t,e d nom P41i a ,i County D1 aS MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST MICHAEL YOUNG 2/23/2026 90 EAST QUAIL RD BELFAIR, WA 98528 WELL SITE ADDRESS: 90 E QUAIL RD, BELFAIR 98528 Pump Make & Model: 2HP 26GPM Pump Set At: 80' Sounder Make& Model:WATERLINE 500 Make& Model: MASTER Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 29 14373 44' 1 29 14402 48' 2 29 14431 49' 3 29 14460 49' 4 29. 14489 49' 5 29 14518 49' STABELIZED 6 29 14547 49' 7 29 14576 49' 8 29 14605 49' 9 29 14634 49' 10 29 14663 49' 15 29 14808 49' 20 29 14953 49' 25 29 15098 49' 30 29 15243 49' 35 29 15388 49' 40 29 15533 49' 800 GALLON TOTALIZATION RECOVERY 0 49' 1 45' 2 44' SIGNATURE: O AND NS PU LNG F rote fr€rr I 3Urk CIL'Unty 1VfI Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 o�uq�asp 360-967-7010 GNo2l f Fo4 COUFORM BACTERIA ANALYSIS FORM late Semple Coilectnd. Time Sample County couecled 2 t 23 ! 2(� fs Typeof Wemr�Sys am(die*onlyone bmr) , / D Group A D Group B .Other V f �I( GroupAandGroupBSystems—ProvidefmmWaterFearI=Ww(4YFi) Q i 0Zc Syslem Nerve ' a 1 R�CfED U CMw Person: DayPhone 38r�ti. CellPhonec( Email Eve.Phone:( Sadrt�A� ailnan0.��cadeore� SAMPLE INFORMATION Semple collected by(namek Sed6cba ale le Spedal hebuctions orcmmentr. C �r TypeofSampto( donlyonolypeofsamplafrantypesllhrw b6below) 1.O Routine DIsM'butlon Sample(AIP) 2.0 Repeat Sample(AIP) Chbrbtated:Yes No ghou an n aBerur�seL magna) Unsatisfactory rmltlne lab number. Cblodne Residual:Totel__Free 3.Ground Water Rule Source Sample - tlrrselisfaebgrorr6teoc4ectdate Chbdnaled Yes__._No D Tfiggaed(AlP) Chorine Residual•Total_Frees._ ❑Assessment(AIP) 4.SurfaceorOW1RewSourraWaterSample(Enumecagan) S DL CoP ❑Fecal ms..n Yea_ 5. SroeCaaaledfarMfamaHonOay: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY D UneatisfactoryTotalCaftrm Present and l SolblaeLory D Eco&present ❑Ecofabsent BaetedeiDensityResults:TotalCcPform ll0Dm1.EcoO rloumL Fecal Cofdo m N00mL I1PC n ml ReplacemontSamplaRequtred: DTNTC DSamptetooeld D Semptavotume DDamagedConbiner D t�err *2026 oZ RuorlTem C UclhodcodorSM9223B DO140dedbD0H Lab UseOdr *Lab error, date was 285i' c7`� corrected on 3/9/2026 by VLJ r rated' orn.MOfl °Co nty.IVY - .