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Home My WebLink AboutWAT2026-00066 - WAT Application - 4/20/2026 WAT 2026 - 00066 MASON COUNTY 415 N.6n'Street ` Shelton,WA 98584 Public Health & Human Services Shelton:360�27-9670,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 I 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) PRrcel Identification Name of Applicant: CLU/I ' 60-10— Ip5s Date: Mailing Address: / & 3 Ff(GLE!(��,,�n(ft4 , ,Phone: ' O" 7c5 ' 7 Parcel Number: S?Rol - -(OX Type of Water System Reason for Application ❑ Public/Community Water System(2 or more 1(( Building permit BLD2026-00274 ,00nnections) 0 Division of land: 2' Individual�er source(one connection), #of Parcels? SPL C7 Well ❑ Boundary line adjustment 0 Spring/surface water 0 ❑ 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) 0 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 7:\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 N Water well report(attached to application). Depth 179 ft. 03/31/2026 Dj Well capacity Test(attached to application) 17 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. 04/07/2026 j� Satisfactory bacteriological test within last year(attach to application). 04/07/2026 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) D( 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: Applicants 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: 10.Anderson 04/20/2026 Date 04/20/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT t DEPARTMENT OF Notice oflntentNo. WE62190 ECOLOGY Unique Ecology Well ID Tag No. BRL 699 Type of Work: State of Washington 19 Construction Site Well Name(if more than one well): ❑ Decommission Original installation NO!No. Water Right Permit/Cerlifcate No. Proposed Use: IN Domestic ❑Industrial ❑Municipal Property Owner Name Dan Hess ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 161 SE Wellswood Way Construction Type: Method: O New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening O Other ❑Dug ll Air- ❑Mud-Rotary Tax Parcel No. 31902-41-00030 Dimensions: Diameter of boring 6 in.,to 179 ft. Was a variance approved for this tell? ❑Yes No Depth of completed well 179 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I ❑ 6 in. +1_5 174 .25 in. O I O O I O Location(see instructions on page 2): 0 WVIWM or❑EWM ❑ ❑ in• in• ❑ ❑ ❑ ❑ NE 1/i-%oftlte SE t/,;Section 02 Totvnsltip 19N Range 03 ❑ I ❑ in. _ in. ❑ I ❑ DID ❑ I ❑ in. in. ❑ I ❑ ❑ I O Latitude(Example:47.12345) 47.16194 Longitude(Example:-120.12345) -123.01667 Perforations: ❑Yes ll No Type of perforator used L Driller's Log/Construction or Decommission Procedure 0 No.of perforations Size of perforations in.by-in. dPerforated from_ft.to_ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and L nature of the material in each layer penetrated,with at least one entry for each change of Screens: E Yes ❑No O K-Packer > Depth 173 fh 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 174 ft.to 179 R. Clay,silt,little fine sand,brown/soft 0 7 Diameter in. Slot size in.from ft.to ft. Silt,sand,some clay,brown/soft 7 16 o Clay,sand,silt,compact,gray/hard 16 34 6 Sand/Filter pack:❑Yes ❑No Size of pack material in. 0 Materials placed from It.to R. Clay,sand,silt,some gravel.brown/hard 34 48 d Sand,gravel,silt,brown/soft 48 73 Surface Seal: I l Yes ❑No To what depth? 18 ft. Sand,gravel,silt,some clay,compact, gray/hard 73 91 L Material used in seal Bentonite Granular 0 Sand gravel,silt,gray/soft 91 113 Did any strata contain unusable water? ❑Yes IN No Type of water? Depth of strata Sand,silt,some gravel, gray/soft,wb 113 120 Method of sealing strata off Sand,silt,finer,less water, gray/soft 120 171 c Coarse sand,gravel,some silt,gray/soft,wb O Pump: Manufacturer's Name N/A Type: heaving 171 179 v H.P. Pump intake depth: 11. Designed flow rate: gpm 4- Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing +1.5 R.above ground surface } Static water level 61 ft.below top of well casing Date 3/31/2026 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) 0 L Well Tests: Was a pumping test perforated? 19 No ❑Yes by whom? I— Yield_gpm with_ft.drawdown after hrs. Q Yield_gpm with_n.drawdown after hrs. 1 t- 26 Z Yield gpm with_fl.drawdown after hrs. y Recovery data(time=zero when pump is turned off—water level measured from well o top to water level) Time Water Level Time Water Level Time "rater Level rn d O U W 4- Date of pumping test 0 Bailer test_gpm with_ft.drawdown after_hrs. NAir test 100 gpm with stem set at 177 ft.for 1 hrs. Date 3/31/2026 Artesian flow_gpm C Temperature of water °F Was a chemical analysis made? ❑Yes ❑O No Start Date 3/30/2026 Completed Date 3/31/2026 0 4) 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. N1 Driller❑Trainee❑PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature (1. Address 1162 NW State Avenue License No. 2253 City.Slate.Zip Chehalis,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072N5 Date 3/31/2026 ECY 050-1-20(Rev 11/18) Ifyou need this document in an alternate format,please call the Water 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. MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST DAN HESS 4/7/2026 18623 ELDBERBERRY ST SW ROCHESTER, WA 98579 WELL SITE ADDRESS: 161 SE WELLSWOOD WAY, SHELTON Pump Make& Model: I HP 15GPM Pump Set At: 120' Sounder Make& Model: WATERLINE 500 Make& Model: Measured in GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 17 124734 50 1 17 124751 52 2 17 124768 54 3 17 124785 55 4 17 124802 55 5 17 124819 55 6 17 124836 55 7 17 124853 55 8 17 124870 55 9 17 124887 55 10 17 124904 55 15 17 124989 55 20 17 125074 55 25 17 125159 55 400 GAL TOTALIZATION 1 53 RECOVERY 2 52 3 51 4 SIGNATURE: ND N MP DRILLING Vanguard Laboratory 2635 Parlanont Lane SW,Suite A Olympia WA 98502 V aaaesD 360-967-7010 GN021/F04 COLIFORM BACTERIA ANALYSIS FORM Date Semple Collected Time Sample County Collected Type of Water System(chedc only one box) ❑GroupA ❑GroupB ,fO,herPVT Group A and Group B Systems—Provide from Water Fadfities Inventory(WFI): ID# System Name: Contact Person: Day Phone: )7Lg4J Cell Phone:( ) Email: /- d^,�� d Eve.Phone:( ) y-Seod toad JOi1S p code ora mall /Ib2 ,W 5k. ,4w G I1≥; , wry 4 Z SAMPLE INFORMATION Sample collected by(name): r'n ^ Specific al' �ere sample collected: Special instructions or comments: )blType of Sample(select only one type of sample from types I through 5 below) 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AlP) Chlorinated:Yes No ((mm distribution system after unsat muise) Unsatisfactory routine lab number. Chlorine Residual:Total_Free 3.Ground Water Rule Source Sample — —— Unsatisfactory routine collect date: Isi I I1.. Chlorinated:Yes No ❑Triggered(Al') Chlorine Residual:Total_Free ❑Assessment(AIP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E coP 0 Fecal FHaed Yw_No_ 5. Sample Cdlected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Cofiform Present and [I Satisfactory ❑Ecolpresent ❑Ecoiabsent Bacterial Density Results:Total Co ifonn /100ml. Ecotl /100ml. Fecal Coliform - /100ml. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Semple too old ❑ Sample Volume ❑Damaged Container ❑ Datelriime necq I Z __o__3 ReceiptTempC: idelhodCoder SM9223B Date Reported to DOH Lab tke Only DOH Lab-Sample# 285- Lt D' J- L3 DOHForm031-319(dixtmO fn.gymlmad 1mµ8ha9aiinentft.d I5250,27(i00R7Yes1711� 77b ad dhm pEfm5ua v�ar8�'n et rn.d3imyd8iiipnata.