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HomeMy WebLinkAboutWAT2026-00078 - WAT Application - 3/4/2026 WAT 2026-00078 MASON CO UNTV415 N.6a'Street . Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services 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 accom p anthis application. Part 1: Applicant) Parcel Identification Name of Applicant: Mark ad Marietta Carector Date: 3.4.2026 Mailing Address: 4240 S Rose St Seattle WA 98118 Phone: 206-679-3301 Parcel Number: 220292190011 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more ® Building permit connections) O Division of land: ® Individual water source (one connection), #of Parcels? SPL IN Well O Boundary line adjustment O Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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. ❑ 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 J:\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 ® Water well report(attached to application). Depth 258 ft. l Well capacity Test(attached to application) 10 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. ld Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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) i Satisfactory ti Determination: . . .. . a ° 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): Reviewer's Signatures: Environ. Health: _ 'tt, Date 4/14/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 a-max i1 !] .... cicT L0 2025 aa �1 DEPARTMENT OF WATER WELL REPORTNotice of Intent No. WE58740 ECOLOGY Unique Ecology Well ID Tag No. BQCI81 Type of\Vork: State of Washington C 1 Construction Site Welt Name(if more than one wall): 13 Decommission Original installation NOt No. Water Right Permit/Certificate No. Proposed Use: I]Domestic 0 Industrial Ll Municipal Property Owner Name Marietta Carector 0 Dewatering 0 litigation O Test Well O Other Well Street Address 6521 SE Arcadia Rd Construction Type: Method: J New wets 0 Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening 0 Other ❑Dug Q Air- 0 Mud-Rotary Tax Parcel No. 22029-21-90011 Dimensions:Diameter of boring 6 in.,to 268 ft. Was a variance approved for this well? 0 Yes Cl No Depth of completed well 258 ft. Construction Details: Wall if yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded 11mad p I ❑ 6 in. 0 258 .25 in. C I 0 LI I O Location(see instructions on page 2): 11 WWM or O EWM 0 I 0 in. — — in. ❑ I 0 ❑ 1 © NE ¼!¼of the JL rh;Section 29 Township 20N. L Range 2• W ❑ E 0 in. _ — in. ❑ i 0 DID ❑ ( Cl in ^ _ in. ❑ 1 ❑ ❑ I p Latitude(Example:47.12345) 47.19762 N Longitude(Example:-120.12345) -122,96176W o Perforations: O Yes 19 No Type of perforator used , a Drillers Log/Construction or Decommission Procedure No.Perforated Sam Size ofperfund surface ns in.by in Formation:Describe by color,character,size of material and structure,and the kind and Perforated from H.to ft.below ground s nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes Ei No ❑K-Packer t Depth ft, information. Use additional sheets if necessary. y Manufactiuer's Name Material From To Type Model No. Diameter Slot size in.from ft.to ft. Brawn silty sand,gravel 0 6 o Diameter Slot size in.from ft.to ft. Brown medium sand 6 21 Brown sand,few gravels,wet 21 74 2 Sand/Iilterpack-Ci Yes I1 No Size of pack material in. Gray sand 74 85 D Materials placed from ft.to H. Surface Seal: 61 Yes ❑No To what depth? 19 ft: Gray silty clay 85 104. Material used in seal Bentonite chips Gray silty sand,few gravels 104 117 E Gra sil cla 117 176 Did any strata contain unusable water? ❑Yes t7 Na D Type of water? Depth of strata Gray silty sand,gravel 176 237 CIvietlrodafseating sirataoff Gray sand,small to medium gravel,water 237 258 Pump: Manufaeturer'sName Typo: H.P._ Pump intake depth: ft. Designed flow rate. gpm Water Levels: Land-surface elevation above mean sea level 227 ft. Stick-up of top of well casing 2 ft.above ground surface Static water level '152 ft.below top of well casing Date 8/20/25 Artesian pressure lbs.per square inch Dale pArtesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test perforated? t l No ❑Yes m by whom? Yield gpm with_ft.drawdown after his. Yield.gpm with_ft.drawdown after—his. Yield_a___gpm with_R.drawdown after_._his. Recovery data(time=zero when pump is turned off—water level measured Corn well D top to water level) Time Water Level Time Water Level Time Water Level °u U Date ofpumping test p Bailer test—gpm with*ft..dmwdown oiler_hrs.} Air test 15 gprn with stem set at 240 ft.for 1,5 ITrs. Date 8120/25 E Artesian flow gpm Temperature of water 50 0 F Was a chemical analysis made? Cl Yes 91 No Start Date 8/19/25 Completed Date 8/20/25 a WELL CONSTRUCTION CERTIr1CATION: 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 into to my best knowledge and belief. O Driller I�i Trainee 2P —Print mes Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 347 City State Zip Shelton,WA 98584 Contractor's IF TRAINEE:Sponsor's License No.2874 Registration No.ARCADD1098K1 Date 8120/25 Sponsor's Signature ECY 050-1-20(Rev 09/18) If you treed this docnmetnt in an alternate format,please call the Water Resomnces 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. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Marietta Carector Well Tag#: BQC181 Site Address: 6521 SE Arcadia Rd, Shelton Depth: 258' Date of Test: 9/2/25 Static: 196.9' Pump Set: 240' TIME GPM LEVEL RECOVERY 1 Min 2 197.5 TIME LEVEL 2 Min 2 197.9 1 Min 200.4 3 Min 5.5 198 2 Min 198.3 4 Min 5.5 199.1 3 Min 197.5 5 Min 5.5 199.8 4 Min 197.1 6 Min 10 199.9 5 Min 197 7 Min 10 201 6 Min 196.9 8 Min 10 201.6 9 Min 10 201.9 10 Min 10 202 15 Min 11 202.2 20 Min 11 204.1 25 Min 11 204.2 30 Min 11 204.3 35 Min 11 204.4 40 Min 11 204.5 45 Min 11 204.5 50 Min 11 204.5 55 Min 11 204.5 1 Hr 11 204.5 1 Hr 10 Min 11 204.5 ;'-Vanguard I aborator} 2635 Parkkmont L rie SW,Suite A, Olympia WA 9$502 VLxOZ7A : 360-967-1010 G1te14ATVIY COL{F©RM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 09/1,912025 I2 c OAM Montt Day Year Type of Water System(check only one box) ❑Group A ❑Group B 1 Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Marietta Ca rector Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( ) Email: a Eve.Phone:( } Send results to:(Print full name,address and zip cod'ore-mail) arietararcadiadriiling.comANDjenn@arcadiad illing.com {•_._ ......_.._.............._.._._ ........ _ ....._.._._. SAMPLE INORMAT[ON Sample collected by(name):Max Specific location where sample collected: Special instructions or comments: BQC191-6521 SE Arcadia Rd,Shelton Counts please Type of Sample(select only one type of sample from types 1 through.5 below) 1.O Routine Distribution Sample(AIP) 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: Isi I / Chlorinated:Yes Nc a ❑Triggered(NP) Chlorine Residual:Total, _Free_ ❑Assessment(AIP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E coli O Fecal Filtered Yes__No_.__.- ,d 5.t Samp?e Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliforrn Present and Satisfactory ❑E.colipresent O E.cotabsent Bacterial Density Results:Total Coliform� __,110oml. E,co1L_._.._...__I100ml. Fecal Colifonn /100ml. HPC I1 mi. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ D e/T me Received: Lab Reference Number Receipt Temp C°: Method Code: SM9223B 922 3 B Date Reported to DOH Lab Use Only: DOH Lab.Sample# 285- c9 I nOR fnmi3C31.?79{e!PecOve Itoc real nia 3pyao irrcm vrra4 d!dCdTi0T{TDWRYm1?t7). TFas eM.a'fietCtsimfin ae an33be ffiI .s4r..xaglvkkinkir,�warsr