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HomeMy WebLinkAboutWAT2026-00068 - WAT Application - 3/25/2026 WAT 2026-00068 • A A M rr 1 I M COUNTY TV 415 N.6'"Street Shelton,WA 98584 Public Health & Human Services sheiton 360-275-9677,Ext.477 Belfair:367-?75-4467,Ext.477 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 completedapplicatio.n with any required attachments for review.. 4. Anaroved building site plan must accompany an this application. Part 1: Applicant/ Parcel Identification Name of Applicant: L'c`"' 1v' . s.,fi' 4 - Date: 3(Z c J Mailing Address: `tl , Srh "c (,.,/� Phone: 3 L - -7 tom-t 2,_. Parcel Number: l'71 1 C'5 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL l Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) o 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) ❑ 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. ❑ t 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:\E}1 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 Water well report(attached to application). Depth ft. >400 Well capacity Test(attached to application) E .. gpm__.._ _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. Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water O 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) ® 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. 0 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: Date 4/1/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT CURRENT un + u,r Original&1'i copy—Ecohtgy.2"°copy—ownrr,3`a copy—driller Notice of Intent No. WE05114 I C�'0iLt0 G,Y ALL364 tConstructionlDecotnmission("x' in circle) Unique Ecology Well ID Tag No. Me Construction Water Right Permit No. EXEMPT WELL Decommission ORIGINAL INSTALLATION Notice Property Owner Name EDWARD&JANE HICKS a5A C/Cl of Intent Number Well Street Address SHADOW LANE (LOT 3) PROPOSED USE: I'?]Domestic ❑ Industrial ❑ Municipal City SHELTON County MASON ❑',DcWatcr ❑Irrigation ❑Test Well ❑Other Location NW 1/4-1/4 NE 1/4 Sec 24 T2 0N R2W e ❑ check TYPE OF WORK: Owner's number of well(if more than one)LOT 3 wwt,t we 0 New well ❑Reconditioned Methrd:❑Dug ❑Bored ❑Driven Lat/Lon (s, r Lat De Lat Min/Sec ❑Deepened O Cable m Rotary ❑Jetted Still REQUIRED) Deg DIMENSIONS: Diameter ofweil -....._..,._inches,drilled 200 tt. Long Deg Long Min/See Depth Of completed well 290 fl• 320012091053 CONSTRUCTION DETAILS Tax Parcel No. Casing m Welded 6 " Diam from+1 ft.to 198 ft Installed: Cl Liner installed " Diam.from fl.to ft• CONSTRUCTION OR DECOMMISSION PROCEDURE Threaded " Diam.from ft.to ft. Formation Describe by color,character,size of material and structure,and the kind and Perforations: ❑Yes ( No nature of the material in each stratum penetrated,with at least one entry for each change of Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY. SIZE-of perfn in,by in.and no.ofperfs_from_ft to ft. MATERIAL FROM TO Screens: ❑Yes L7,]No ❑K-Psc Location. GRAVELLY BROWN FINE SAND,SILT BOUND 0 Manufacturer's Name TIGHT,DRY 24 Type Model No. BROWN PEA-GRAVELLY FINE SAND,LOOSE, 24 Diem. Slm.size from R.to ft. 36 Otani. Sldt size from ft to ft. DRY Gravel/Filter packed:O Yes 0 No O Size of gravel/sand BROWN PEA-GRAVELLY LOOSE SAND, 36 Materials placed from ft•to ._...-----ft• MOIST 59 Surface Seal:f Ycs ❑No To what depth?2Q fl. GRAY GRAVELLY SILTY CLAY.MOIST,STICKY 59 112 Material used iii seal BENTONITE CHIPS BROWN SANDY GRAVEL,SILT BOUND, 112 Did any strata contain unusable water? ❑Yes m No TIGHT,MOIST 135 Type of water? Depth of strata GRAY STICKY CLAY 135 175 Method of seating strataolf BROWN SANDY GRAVEL,LOOSE,MOIST 175 185 PUMP: Manufacturers Name BROWN SANDY GRAVEL,LOOSE,WATER 185 200 Type: H.P. WATER LEVELS; Land-surface elevation above mean sea level_ ft. Static level _ft.below top of well Date 8/9M6 Artesian pressure ._lbs.per square inch Date Artesian water is controlled by (cap,valve,etc: WELL TESTS: Drawdown is amount watcrlevel is lowered below static level Was a pump lest made?❑Yes 1 No l f yes,by whom? Yield: gal.lmin,with H,drawdown after __lies: Yield; uallff in.with ft.drawdown after �lire. Yield: izal.lmin.with ft.drawdown after,_ hrs. Recovery data(rime taken as zara when pump turned of,(water level measured from well rap to water level) Time Water Level Time Water Level Time Water Level n n Date of test wV V Bailer test gal./min,with ft.drawdown after_ _lies, Airiest• D gal./min.with stem set at 180 ft.for.'L......._.._ _hrs. t § . Artesian flow g.p.m. Date Temperature of water 51 Was a chemical analysis made? ❑Yes ®No e �t1.t O vcO Q Start Date 8/8/06 Completed Date 9/9/06 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. Driller DEngineer OTratnee Name(Print)BRANDON HICKS Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature �"450 — Address PO BOX 1790 Driller or trainee License No.2785 City,State,Zip SHELTON WA 98584 ifTRAINEE, Contractor's Driller':Licensed No. Registration No. ARCADDI098K1 Date 8/11/06 Drillar's Signature ECY 050.1-20(Rev 3105) Ecology is an Equal Opportunity Employer. Arcadia Drilling Inc. R.O. Box 1790 Shelton, WA. 98584 Customer: Scott White Well Tag#:ALL364 Site Address: 100 E Shadow Ln, Shelton Depth: 200' Date of Test: 314126 Static: 155.6' Pump Set: 180' TIME GPM LEVEL f RECOVERY 1 Min 13.5 156 TIME LEVEL 2 Min 13.5 156 1 Min 155.6 3 Mn 13.5 156 4 Min 13.5 156 5"Min 13.5 156 6 Min 13.5 156 7 Min 13.5 156 8 Min 13.5 156 9 Min 13.5 156 10 Min 13.5 156 15'Min 13.5 156.1 20 Min 13.5 156 25 Min 13.5 156 30 Min 13.5 156 35 Min 13.5 156.1 40 Min 13.5. 156.1 45 Min 13.5 156.1 50 Min 13.5. 156.1 55 Min 13.5 156.1 1 Hr 13.5 156.1 Total Gallons Pumped: 810 Gallons Vanguar� Lab�ratoiy;;;. 2635.Parkmont Lane SW,Suite A tJlynpia WA 98502 rro€a 360-967-7010 G0LIF0RM AC' EtlA ANALYSIS FORM .a Date Sample Collected Time Sample County Collected Mason 3/04/2026 0 o C M AM nib nay Yom -:_D PM ie of_Water System(check only one box) Q Group A Q Group B ®Other sup A and'Group'B Systems-Provide from Water Facilities Inventory(WFI): item Name: Scott White itact Person:Arcadia,Drilling,Inc y Phone:(360 )426-3395 Cell Phone:( } ail• Eve.Phone:( ) id;rasaits`to;(Print rug name,address and zip code ore-mail) etn@arcadiadriiting.com AND)onn Jarcadiadrilling;.com mpiecoilectedby(name):Shad ecifclocatlor where sample collected: Special instructions or comments: L364-100 E Shadow Ln,Shelton Counts please• pe o#,Samle(steles only on a ipa. sample from types 1 through S below) j Routine Distribution Sample(A(P) 2.0 Repeat Sample(AJP) 'hlorinated:Yes No (from distribution system after unsaL routine) Unsatisfactory routine lab number. ,hlorine Residual:Total_Free..._.... 'round Water Rule.Source Sample Unsatisfactory routine collect date: 1 1 Chlorinated:Yes.,, .No Triggered(ArP) Chlorine Residual:Total_ Free.- Assessment(NP) Surface orGWl`Raw-Source.Water Sample(Enumeration) E.cog 0 Fecal Filtotod Yo_No_._ Sample Collected for Information Only: LAB USE OILY DRINKING WATER RESULTS LAB USE QNt Y Unsatisfactory Total Colifomi Present and. ]Satisfactory Q Ecofiprfsent Q E.cofabsent cterial Density Results:Total Coliform, <1,0 1100ml. E.coli<1•0 d100mi. cat Colifotm' X110©ml. HPC 11 ml. placement Sample Required: O.TNTC Q Samplet000ld SampleVoluine Q'Damaged Container Q. r7Lrn �. ;6i tTempCay M,3tnooco e SM9223B to Repoited:to DOH Lab Use Only: ,H LatrSample# D.n+i Parn X43135{txtira 0Ol?l1txnand NM u.. Irri tvmmt iii t+TOdf1P7 ntrOiflY1'31 ii„ TNs ad 4W,1 ei47Ceftt ua avmstra atwuaAaLuaq;drfrkin9wavr.,