HomeMy WebLinkAboutWAT2026-00071 - WAT Application - 4/17/2026 WAT 2026 - 00071
415 N.6a'Street
l2im II• 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 lie 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 of Applicant - \O Date: J4ARGt1 �5 ZDZ to
Mailing Address: ) j K Inc!✓1 L-rOr�l W .A- Phone: Ac7 - L4- 49
Parcel Number: LZC Za-7 Srx�Z3O
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit BLD2026-00286
connections) 0 Division of land: _.
{
Individual water source(one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
0 Springlsurface,water '❑ Other(explain)
o 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 PubliclCommunity 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)
o 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.
0 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
Jt\EH Fonns\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 34 1 ft. 02/01/2024
Well capacity Test(attached to application) 4.1 - 11.1 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. 09/09/2025
' f Satisfactory bacteriological test within last year(attach to application). 09/10/2025
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)
1ffi Satisfactory Determination;
This determination does not address adequacy of the,distribution system,guarantee an adequate supply of
water Intieflnitely In the future,or guarantee compliance with all applicable WD0R 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
86.70A ROW.
b. Unsatisfactory Determination
Applicant's water supply not appear adequate to meet the needs of Its Intended use for the following
reason (s).:
FH•APPR0VED Reviewer's Signatures
Environ. Health:
ndei'uK64n1W2625 Date. . . .;94/17%202S.
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT DIiPARTMENT Of- Notice oflntontNo. WE55217 I
E Ca LO GY Unique Ecology Well ID Tag No. BPF163
Type of Work: Stake of Washington
7 Site Well Name(if more than one well):
1 Construction
❑Decomutission b Original installation N0I-No, Water Right Permit/Certificate No.
Proposed Use, IN Domestic El industrial. ❑Municipal Property Owner Name Seth Homan
❑Dowatering ❑Irrigation ❑Toe Wail O 0ther*
Well Street Address 780 W Wvnwood Dr
Cons truct Ion'Cyper Mei4odi
Si New well ❑Alteration ❑:.Drivdn ❑Jetted ❑Cable Tool City Shelton County Mason
❑Deepening ❑Other ❑Dug Ill Air- ❑Mud-Rotary Tax Parcel No. 42026-75-00230
Dimensions;Diameter of boring_6 in.,to 341 R Was a variance approved for this well? ❑Yes D No
Depth ofcompltted well 341 ft,
Construction Details; Wall If yes,what was the variance for?
Casing Llnor Diameter Prom To Thickness Steel PVC Welded Throad
I O 6 in. 2_. V8 ,26 in. O I ❑ t I O Location(see instructions on page 2): 19 WWM or❑11WM
❑ I O in. In. O I ❑ ❑ I O NW '/e-'/e of the SE %;Section 25 Township 20N Range iL.
❑ I ❑ _ in. O I ❑ ❑ I O
❑ 1 ❑ in, ` __ in. ❑ I ❑ DID Latitude(Example:47.12345) 47.19364
Perforations; ❑Yes No 19 Longitude(Example:-120.12345) -123.12495
Typo of perforator used
No.ofperforations Size ofporforations-in,by_in. Driller's Log/Construction or Decommission Procedure
Porfbmted from ft.to ft.below ground surface Formation:Describe by color,character,size of material and surer re,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens; Si Yes ❑No Si K-Packer C ' Depth 335 it. infonnntion, Use additional sheets if nucossttey.
h[nnufacttrcr's Name Alloy Machine Works Material From To
Type Wire-wrapped Model No,
Diameter 5_ Slot.sizo.018 fa.from 336 h,to 341 it, Brown fine ravel and sand,siltbinder sharp 0 22
Diameter__-_. Slot Size„in.fro,4 It to_it. Brown fine to medium sand and gravel,siltbinder. 22
loose 48
Snad/Futerpacicr❑Y4s IS No Sizaiifpeckmaterial ini Multi-colored medium gravel and sand,siltbinder 48 Materials placed thorn_ft It',to_.__h:
Surface'Sealt Si Yes 17 No To what do th? 8 ft, iOOse 72
p Brown silt and sand,weeps 72 83 Material used;n sea[ Bentanite chips
Did any strata contain unusable water? ❑Yes I]No Gray fine to medium sand and gravel,weeps 83 93
Typo ofwater? Depth ofstrata Fine slltbound sand,multi-colored gravel 93 109
Method of scaling strata off Fine silt and sand,weeps 109 120
Gra silt,wet 120 123
Pumpt Manufacturer's Nemo Typo: Gray sand and silt 123 129
H.P. 1 ump9ntake depth:__ft. Designed flow rate: gpm
Gray silt and clay,gravel 129: 141
Water Levels;Landsurfaceolovation.abovamean semi level 340 ft. Fine silt and pea gravel,loose
Stick-up of top ofwell casing 1_ gravel and slit 167 e Fine ft•above ground surface 141 7 167
Static watcrlevel 248 ft,below top ofwoll co ing Date 211/24189
Artesianpreseure_____lbs.persqunccinch Date Red arid brown fine gravel and slit 1,89 220
Artesian water is controlled by (cap,valve,etc,) Red and brown fine gravel and silt :220 243
Well Tests. Gray fine gravel.and silt : 243 261
Was a pumping.test performed? 10 No ❑Yes ' ' by whom? Gray silt and sand 261 290
Yield_gpm.widr_lt.drawdown a1er`lira. Gray silt and sand,gravel 280 295
Yield_gpm with—ft dmwdown alter_hrs. Gray clay,moist 295 305
Yield gpm with_11.dmwdown alter__hrs. Brown compact clay 305 315
Recovery data(tine=zero when pump is turned off—water level measured from well Gray clay,hard 315 320
top to water love[) Green clay,hard,moist 320 335
Time Water Level Time Water Level Time Water Level
Black One sand,multi-colored fine to medium 335
ravel,water bearing 341
Date ofpumpiug test —~
Baiter teat spin with It.dmwdown after hrs.
Airiest 12 g _pm with atom sot at 320 IL for 1— bus. I-Date 1/31/24
Artesian flow gpm J
Tempeesture of water.=3. 'F Was nchaniioal.analysia.made? ❑Yes IS No Start Date 1/26/24 Completed Date 2/1/24
WELL CONSTRUCTION CRIt' ICA1r ON lconstmetedaod/or accept responsibility for construction of this well,and its compliance with all Washington well
oonsttuction standards Materials used and the infomiarttq>t reported above are true td my best knowledge and belief.
Si Driller O Trainee El PE—PrintName q P' Ian Drilling Company Arcadia bribing Inc.
Signature Address PO Box 1790
License N6.2063 City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No Contractor's
Sponsor's Signature Rogistration.No.ARGADD109SKI Date 2/1/24
ECY 050-1-20(Rev 09/18) ifyort need this doctunenl In an alternate format,please call the Water ResottrcesProgram at 360.407.6872.
Pe.e14
on,e with-/tearing loss can call 7lI foi Washington Relay Service. Persons with a speech disability can call 877-833-634/.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer:Seth Homan Well Tag#: BPF163
Site Address:780 W Wynwood Dr, Shelton Depth:341'
Date of Test:919/25 Static: 249.6'
Pump Set: 320'
TIME GPM LEVEL RECOVERY
I Min 4.1 250.3 TIME LEVEL
2 Min 4.1 251.7 1 Min 263.7
3 Min 4.1 251.2 2 Min 261.3
4 Min 4.1 251.6 3 Min 260.2
5 Min 7.7 251.8 4 Min 258.2
6 Min 7.7 252.5 5 Min 257.1
7 Min 7.7 253.6 6 Min 256.9 I!
8 Min 7.7 254 7 Min 256.5
9 Min 7.7 254.3 8 Min 256.3
10 Min 9.4 254.5 9 Min 256
15 Min 11.1 257.9 10 Min 255.8
20 Min 11.1 259.5
25 Min 11.1 260.6
30 Min 11.1 261.4
35 Min 11.1 262.4
40 Min 11.1 262.9
45 Min 11.1 263.5
50 Min 11.1 264.1
55 Min 11.1 264.5
1 Hr 11.1 265.1
1 Hr 10 Min 11.1 265.7
1 Hr 20 Min 11.1 266.5
Total Gallons Pumped:730.3
V.
Vangixaid L'b9latory
2635 PaiktriontL e SW,Suite A
QlyrrtP1a A.9852 `
vzo Aapy SGO 9G7F1010
CQLIFtRMA.l ARIA ANALYSIS FARM
Date Sample Collected Time Sa)npte County
Collected Mason
O9/09/2025 3 ;, a 13AM
•__ INIPM
Month Day Year —'""—
Type of Water System(check only one box)
0 Group A ❑Group B Q Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID# _____
System Name: Seth Homan
Contact Person:Arcadia Drilling,Inc
Day Phone:(360 )426-3395 ell Phone:( )
vs.Phone:
Email; ( )
Send results to:(Print full name,address aril zip cede r e-mail)
arieta@arcadiadrilling.comANDIenncarcadiadril ng.com
SRMPLE INFORMATION
Sample collected by(name):Shad I I
1 I
Specific location where sample collected: Special Instructions or comments:
BPF163-780 W Wynwood Drive,Shelton
®ants please
Type of,Sample,(select only one type of sampl front types;I IhrQugh 5 below)
1.0 Routine Distribution Sample(AIP) a.0 Repeat Sample(AIP)
Chlorinated:Yes___No (from distribution system after unsat,routine)—
outine)
Unsatisfactory routine lab number:
Chlorine Residual:Total—Free_,—
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
Chlorinated:Yes No
O Triggered(AIP) Chlorine Residual:Total__Free_.._,.
0 Assessment(AIP)
4. Surface or GWI Raw Source Water SamplO(E umnumn eration) L S
❑E Coll O Fecal Filtered Yes_No- 1i
5.19 Sample Collected for Information Only; t
tAB U ONLY DRINItIN WA ER RESULTS LAS USE ONLY
0 Unsatisfactory Total Collform Present and Satisfactory 1 I
❑Ecollpresent ❑E.colla sent
Bacterial Density Results:Total Coliform < •0 100ml. E ao/l <1--0 /loom].
Fecal Colifomf 1100ml. PC 11 ml.
Replacement Sample Required: 0 TNT ❑Sample too old
0 Sample Volume ❑Damaged Contain r 0
Date/rIIpa Received: Fab Reference Number
Receipt Temp C: AeUrod Code:
Date Reported to DOH 1.ab Use Only:
DOH Lab-Samples
285-Nino
i I
DOH Form 03I.19 e o I lymnoed8dop 8 don an t«mMa bermi,W1 880.525.e1 (rrU1TTY dill).
Ill,doer pubfcnbone are ahtoet rmm.dohwapovPodrbesrmler.