Loading...
HomeMy WebLinkAboutWAT2026-00004 - WAT Application - 3/30/2026 WATd" ( r MASON COUNTY 415 N.6u Street J , Shelton,WA 98584 Public Health & Human Services Shelton:360-275-4467,Ext 400. Belfair:360-275-4467,Exi,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: 1 r1 CCt Date: - Mailing Address: TiY3Y I 3I L ` one: Parcel Numbe ` 7s flli ( i4 9?)5EH Q( ( U Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit ' ,-1 2,O2 co.� O 3 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL C\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 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 I of 2 � r Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well IA Water well report(attached to application). Depth 288 ft. G.� Well capacity Test(attached to application) 6-18.5 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. K] Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) O 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) ® 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). Reviewer's Signatures: Environ. Health: Date 3/30/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT , DEPARTMENT F Notice of Intent No. WE61896 ECOLOGY Unique Ecology Well ID Tag No. BRG681 Type of Work: State of Washingtor. IN Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOl No, Water Right Permit/Certificate No. Proposed Use: `Domestic O Industrial ❑Municipal Property Owner Name Karin Leaf O Dew•atering O irrigation ❑Test Well ❑Other Well Street Address 151 SE lamret Rd Construction Type: Method: A]New well G'Alteration O Driven O Jetted ❑Cable Toot City Shelton County Mason ❑Deepening ❑Other O Dug ©Air- ❑Mud-Rotary Tax Parcel No. 31901-50-00903 Dimensions: Diameter ofbormg 6 in.,to 290 ft. Was a variance approved for this well? 0 Yes l]No Depth ofcompleted well 288 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread C ( O 6 . in. 0 288 .25 in. C ❑ I O Location(see instructions on page 2): C■WWM or❑EWM ❑ l ❑' in. NW in. ❑ ❑ ❑ i ❑ Y+-'/of the NE '/;Section 1 Town 1 ship 9N Range 3W ❑ O in. r in, ❑ j ❑ ❑ ) ❑ ❑ s ❑ in. in. ❑ ( ❑ ❑ ❑ Latitude(Example:47.12345) 47.16821 N Longitude(Example:-120.12345) -123.00003 W Perforations: O Yes no No Type of perforator used No,of perforations Size of perforations in,by_in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to_ft below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes 1]No O K-Packer Depth_ft, information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size in.from ft.to ft. Brown sandy loam 0 2 Diameter Slot size in.from ft.to ft. Brown silty sand 2 11 Brown clay,sand and gravel 11 28 Sand/Filter pack:❑Yes No Size of pack material in. Materials placed from ft,to_ft. Brown silty sand,few gravels 28 113 Gray silty clay,layers of gray sand,wet 113 146 Surface Seal: Yes O No To what depth? 18 ft. Gray Silt Cla 146 251 Material used in seal Bentonite Chips Did any strata contain unusable water? O Yes J No Gray sand,gravel,water 251 260 Type ofwatcrr Depth ofstrata Gray silty sand,gravel 260 278 Method of sealing strata off Gray coarse sand,gravel,water 278 290 Pump: Manufacturer's Name Type: H.P. Pump intake depth:____ft. Designed flow rate:_gpm Water Levels: Land-surface elevation above mean sea level 136 ft. Stick-up of top of well casing 1;5 ft.above ground surface Static water level 127 ft,below top of well casing Date 2/25/26 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? O No O Yes b by whom? Yield _gpm with—ft.drawdown after—hrs. Yield _gpm with—ft.drawdown after_hrs. Yield_gpm with_it.drawdown after hrs. Recovery data.(time=zero when pump is turned 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 .30 gpm with stem set sr, Q_:ft.for j_hrs. Date 2/25126 Artesian flow_gpm Temperature of water 51 °F Was a chemical analysis made? ❑Yes ]No Start Date 2119/26 Completed Date 2/25/26 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(1 Trainco-5 PE—Print I lamJames Johnson Drilling Company Arcadia Drilling Inc. Signature .._- Address PO Box 1790 License No.'8479T City State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2874 ., Contractor's Sponsor's Signature Registration No.ARCADDI098KI Date 2/25/26 ECY 050-1-20(Rev 09/18) If you 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. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Karin Leaf Well Tag#: BRG681 Site Address: 151 SE Iamret Rd, Shelton Depth: 280' Date of Test: 3/16/26 Static: 129' Pump Set: 260' TIME GPM LEVEL RECOVERY 1 Min 6 130.2 TIME LEVEL 2 Min 6 131 1 Min 136.3 3 Min 6 131.7 2 Min 133.7 4 Min 6 132.1 3 Min 132.2 5 Min 12 132.7 4 Min 131.2 6 Min 12 135.2 5 Min 130.7 7 Min 12 136 6 Min 130.3 8 Min 12 136.2 7 Min 129.9 9 Min 12 137.2 8 Min 129.7 10 Min 18.5 137.7 9 Min 129.5 15 Min 18.5 143.6 10 Min 129.2 20 Min 18.5 144.3 11 Min 129.2 25 Min 18.5 144.7 12 Min 129.1 30 Min 18.5 144.9 13 Min 129 35 Min 18.5 145 40 Min 18.5 145.2 45 Min 18.5 145.3 50 Min 18.5 145.5 55 Min 18.5 145.5 Total Gallons Pumped: 1027.5 Gallons PO rE≥l MA AOEt E P4T LABORATORIES I'I if i, y�st 15158Oth S E,Tacoma,WA 9840.4+ yp� COLIFORMi Air- ERCi NAL $IS. Ri 1 .. Date Sample Collected Time Sample County 0001 Dy Year m m Type of Water System(check only one box) E1 Group A ❑Group B Other Group A and Group S Systems-:Provide from Water Facilities Inventory(WFI): lDx System htame: '''( Contact Person: Day Phone:Ca l 2{t'- Cell Phone;,f Email: Eve.Phone:`( Send rits zit fall name,address a zip tab � t00 rn :. M... .... SAMPLE INFGRNiAT1f3N Sample collected by(name); Specific ocation where sample collected: Special instructions or comments: Typo of Sample satecto ly6sre type of sample firn 1ypds•1 tlnUgh below) t.0 Routine Distribution Sample(AlP) 2,.C] Repeat Sample(AlP) Chlorinated:Yes......_.............. ?:_.._..:.._ (torn disbibut`aorr system alter�Mnsa}routine) • Unsatisfactory routine lab number: Chlorine Residual:Total,_-Free,. 3 Ground Water Ru€e.Source Sample Unsatisfactory routine collect date: ,_,,.,,,,.,.,..,. ..,........ ..-.••..••..l—. __...... Ch€orinated:Yes No o Triggered(A.P) Chlorine Residual:Total,___Free. a Assessment (AlP) _...� .__..._._._._..._........ ....................__.. 4. Surface or GWI Raw Source,Wa₹er Sample(Enumeration) S ©E:colt ❑Fecal ru a Yes _ —_ ample Cel#aated far'intonnatlon b9nty: SAS USE ONLY . DRINKING WATER RESULTS LAB USE ONLY 0 U'nsattsfactory Total Wiform Pram@ and Satisfactory 0 Ecoti present; _ 0 Ecoliabsent ,Bactertal.Density Results:Total Gollfam n Jt00mi. E:coli 3100mni. Fecal Conform_..__ _ I1OOml. HPG ft mi. Replacement Sample Required: 1 TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0 te. +me F2 Lab Rn€eresae,Numtrar Receipt Temp C: Method Code; ` 22' :, .._........... Date R " lied to DOH — Lab Use Only: DOli Lab-sample# 089 __ r;0 s'3� Cal7 r5 s4r msi6a era rise stirro ea'urn:^2,.512'fl'a`3≤T7Yeai711t `2'�ta��r ��'=e*II ash a�a�3�e(Mvsret�6ssa.3c„r h�zvxps,Y.Ez.