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HomeMy WebLinkAboutWAT2026-00067 - WAT Application - 4/15/2026 WAT P - 415 N.6!h Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services Belfair: 360-275-4467,Ext400 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 f , Name of Applicant: ' `'t' - >Date Mailing Address: 'Cl �� } � WA �t Phone: • "i Parcel Number: I v `H _ dO 3C✓ Type of Water System Reason for Application Public/Community Water System (2 or more 0. Building permit ( �� connections) O Division of land: ❑ Individual water source (one connection), #of Parcels? SPL Well O Boundary line adjustment t5 Spring/surface water ❑ Other(explain) ❑ Other(explain) O Replacement or Remodel(please indicate,name /f 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 WEL2025-00036 Name of Water System: K\ 1 V 1 LL 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 p connection(s) in use.This will be the \$ v.J 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 aL3_ 3c11,�I Signature of Water System Manager t,.r` ir Date This form may be scanned and available for publiew at www.masoncountywa.eov J:\EI{Fonns\Drinking Water Revised 05108/2024 Page 1 oft Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well IZ Water well report(attached to application). Depth 56 it. 04/29/2025 l�l Well capacity Test(attached to application) —12 gpm 800 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, f� a well capacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. 05/23/2025 I$f Satisfactory bacteriological test within last year(attach to application). 06/21/2025 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) Satisfactory DetermrnatioW. This determination does not address adequacy of the distribution system,guarantee an adequates'u.ppiy of wafer 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 04:0-Determination of Adequacy for Building Permits are satisfied. Additional,Growth Management requirements.may apply Chapter 36 70A RC1N. D Unsatisfactory Determination: Applicant's 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: ,I�An�*MM 04/15/2026 Date 04/15/2026 This form may be scanned and available for public view at www.masoncountvwa.aov Page 2 of 2 WATER WELL REPORT t DEPAWI MIH1T OF Notice of Intent No. WE59160 ECOLOGY Unique Ecology Well ID,rag No. BQC100 TypeofWork: State ofWashington &I Constriction Site Well Name(il more than one well): O Decommission z • Original installation NOl No. Water Right Permit/Certificate No. Proposed.Use: O Domestic' 0 Industrial ❑Municipal Property Owner Name David King 0 Dewatering 0 Irrigation 0'rest Well 0 Other Well Street Address 173 E Nelson Rd Construction Type: Method: l New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Allyn County Mason ❑Deepening 0 Other 0 Dug C7 Air- 0 Mud-Rotas• Tax Parcel No: 12229-44-00030 Dimensions: Diameter of boring 6 in.,to 56 ft. Was a variance approved for this well? ❑Yes ❑' No Depth of eoinpleted well 56 Ii. If yes,what was the variance for? Construction Details: Will Casing Liner Diameter From To 'thickness Steel PVC Welded Thread cif 1 ❑ 6 in. 0 52_ .25 in. f.3 I 0 1 I ❑ Location(see instructions on page 2): ©WWM or O EWM 0 0 in. _ in. 0 0 0 I ❑ SE /,-'Ve of the SE ''/ Section 29 TownsliipL Range JL ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.36160 N Longitude(Example:-120.12345) -122.82637 W Perforations: ❑Yes No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Lng/Conacter. ize or Decommission Procedure Perforated front ft.to It,below ground surface Faturof o n:Describe by color,character,size of material and structure,and the kind and nature orthe material in each layer penetrated,with at least one entry for each change of Screens: R Yes ❑No GJ K-Packer c* Depth 50 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5" Slot size.018 in.from 51 ft.to 56 ft. Brown clay,round fine to medium sand&gravel 0 31 Diameter Slot size_in.from -ft.to n. Brown fine to medium sand,water 31 52 Brown medium sand,few gravels,water 52 56 Sand/Filter pack:0 Yes ❑O No Size of pack material in. tvlalerials placed from.-11.to_ft. Surface Seal: I]Yes 0 No To what depth? 18 ft. Material used in seal Bentonite chips Did any strata contain unusable wafer? ❑Yes 17 No Type of waler? Depth ofstratu Method ofsealing strata off Pumps.\-lanufacturer's Name Type: H.P. Pump intake depth: ft. Designed flow rate: gnat Water Levels: Land-surfaceelevation above mean sea level 54 it. .Stick-up of top of well casing __'fl.above ground surface Static water level 20 ft.below top of well casing Date 4129125 Artesian pressure lbs.per square inch Date - Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test perfnnned? a❑No ❑Yes r' by whom? Yield'_gpm with—ft,drawdown after Its. ---- Yield_gpm with_R.drawdown after_his. Yield Spin with_ft.drawdown alter hrs. Recovery data(tine=zero when pump is turned off—water level measured front well top to water level) Time Water Level Time Water Level 'lime Water Level -- Date of pumping test Bailer test . pm with_It.drawdown after_lira,1 Air-test 15 Spin with stem set at 40 ft.rot 1.5 hrs. Daly 4129/25 Artesian flow_'mint Temperatureofwater 50 °F Was achemical analysis made? ❑Yes 1J No Start Date 4/29/25 Completed Date 4/29/25 WELL CO STRU(."IIO\CPRI'IFICAT ION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington%cell construction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller O Trainee O PEy Print Name J mt s r hnson Drilling Company Arcadia Drilling Inc. Signature vt e_-L -, Address PO Box 1790 License No. 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2874 Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Date 4/29125 ECY 050-1-20(Rev 09/18) 1fyou need this docttnteni in an aliernaie forutal,please call the fVaterResotb•ces Progrmn at 360-407-6872. Persons rridt hearing lass crnrcul1711 jar 1Vashington Relay Service. Pe,swrrs irith a speech ilisahililp can ca1I877 433-634/. Vanguard Laboratory V 2635 Pttrkmorit-Latie SW,Suite A Olympia WA 98502 - ,ogaq,�ry 360-967-7010 COLIFORM.BACTERIAANALYSIS FORM Date Sample Collected Time Sample unty Collected Easonc' 06/19/2025 Ie 4 s oA Math, Day you — —�°PM Type of Water System(chock only one box) ❑Group A ❑Group B I Other Group A and Group B Systems—Provide from Water Facilities Inventory('NFI): IDR .� _—_ System Name: David King ^_____, Contact Person:Arcadia Drilling,Inc Day Phone:(390 )428.3395 Cell Phone:( Email: Eve,Phone:() Sand results to:(Print full name,address and zip code or o-maO) ederaQarcadladnlling.com AND lenn@arcadiadrllralg.com SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Special insimcllons or comments: BQC100 173 E Nelson Rd,Allyn Counts please Type of Sample(select only one type of sample from types I through 6 below) 1.❑Routine Distribution Sample(NP) 7_❑ Repent Sample(AIP) Chlorinated:Yes__-No___. (from dlsidbuaon system afterunsal routes) v � Unsatisfactory routine lab number: Chlorine Residual:Total—_Free. 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: Chlorinated:Yes_No___ ❑Triggered(NP) Chlorine Residual:Total__,_.Free___.- 0 Assessment(NP) _ 1 4.Surface or GWI Raw Source Weller Sample(Enumeration) r I I ❑F.col! ❑Fecal Pesos Yos_No___ 5.[}Semple Collected for Inlorinalton Only: — - I LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifomr Present and Satisfactory ❑E.coll present O Ecoli absent —.-- Bacterial Density Results:Total Coliform_<i Q_J100mi.Ecoli.<l.0 1100ml. II Fecal Coliform n/a 1100ml. HPC._ n/a__J1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑Sample Volume O Damaged Container ❑ oalwllrue Roc Iwd: lab Reference Number A. I 1 Q OlA2Q Receipi Tamp C°: 61allod Code: t_� 0 SM9223B Date Reported to Boil Lab Use Only: 06/21/ j_____ DOH Leb-Samp!ef) 285-62015 Arcadia Drilling Inc. P.O.Box 1790 Shelton,WA.98684 Customer:David King Well Tag#:BQC100 Site Address:173 E Nelson Rd,Allyn Depth:56' Date of Test:6/23/25 Static:20.7' Pump Set:40' TIME GPM LEVEL RECOVERY 1 Min 4.2 22.9 TIME LEVEL 2 Min 4.2 24.1 1 Min 29.5 3 Min 4.2 24.9 2 Min 25.9 4 Min 4.2 26.3 3 Min 24.1 5 Min 8.3 25.5 4 Min 23.2 6 Min 8.3 27.3 5 Mtn 22.6 7 Mtn 8.3 28.5 6 Min 22.2 8 Min 8.3 29 7 Min 21.9 9 Min 8.3 29.3 8 Min 21.8 10 Min 12 29.6 9 Min 21.6 15 Min 12 34.8 10 Min 21.6 20 Min 12 35.2 25 Min 12 35.35 30 Min 12 36.5 35 Min 12 35.6 40 Min 12 36.7 45 Min 12 35.7 50 Min 12 35.7 55 Min 12 35.75 1 Hr 12 36.8 1 Hr 10 Min 12 35.9 Total Gallons Pumped:778.3 Gallons ii {