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HomeMy WebLinkAboutWAT2025-00231 - WAT Application - 11/4/2025 WAT - UO _ 415 N.601 Street • If Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services Belfair:,360 275-44b7,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 accompany this application. Part 1: Applicant/ Parcel Identification 11/4/25 Name of Applicant: Matt and Kaida Wees Date: Mailing Address: 353 E Sunny Woods Rd W Phone: 360-561-3072 Parcel Number: 321163390082 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ER Building permit'` Jk t 2 2.5-0 k3.p connections) 0 Division of land: E* Individual water source(one connection), #of Parcels? SPL IN Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ 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) 0 1 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 J\EI=I.F ones\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 l Water well report(attached to application). Depth gg ft. >400 ' LX Well capacity Test(attached to application)— 1 7 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. lR Satisfactory bacteriological test within last year(attach to application). 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) l 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: Applicants,water supply does not appear adequate:to meet the.needs of its Intended use for the following reason(s) Reviewer's Signatures: Date -5/8/2026 Environ. Health: This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT OF NoticeoflntentNo. WE01237 ECOLOGY Unique Ecology Well ID Tag No. BRR 200 Type ofWorkt State of Washington no Conduction Site Well Name(if more than one well): ❑ Deconmtission = Original installation NOl No. Water Right Permit/Certificate No. Proposed Use: let Domosllo ❑Industrial ❑Municipal Property Owner Name Mathew Weeks ❑Dewatcring El litigation ❑Test Well ❑Other_____________ Well Street Address, 353E Sunny Rd W ComlructlonTypei Mellrods City Shelton County Mason 1]Now well O Alteration ❑Driven 13 Jetted ❑Cable Tool El Deepening ❑Other ❑Dug @1 Ain ❑Mud-Rolary Tax Parcel No. 321169.33-90082 Dlmenslonss Diameter OFboring 6 in.,to 100 ft. Was to variance approved for this well? D Yes ©No Depthofeompletedwall 09 R. If yes,what was the variance for Construction Delallst Wall ?Casing Liner Diameter From To Tlsiekness Steel PVC Welded Thread ❑. I ❑ e in. +1 94 .26 in. !O I El El ❑ Location(see instructions on page 2): I1 WWM or❑EWM ❑ I ❑ in. --- _in. ❑ I ❑ a I ❑ SW 'r %of Iho SW %;Su clicn 15 Township 211 Range 03 ❑ I ❑ in. — — in. ❑ I ❑ ❑ I El Latitude(Example:47.12345) 47 30250 OJO _in, _ — .—in. ❑ I ❑ ❑ I ❑ Longitude(Example:-120.12345) -123.07801 Perferattont ❑Yes 17 No Type ofperfiralorused Driller'sLog/Constritcllon or Decommission Procedure No.ofperforations_, Size ofperfomlions_In,by_in. Formation Describe by color,character,size ol'nraterial and mruoturo,and the kind and Peribrated from-____R.to,__ft,below ground surface nature ofthe material in each layer penetrated,with at least one entry for each change of Screens: ©Yes O No N K Packer t Depth 83 n. informattott. Use additional heels If necessary. Manufaoturer'a Name Johnson Materiel From To Type Stainless Steel Model No. Top Boll 0 1 Diarnotcr 5 In. Slot sizs ,019 in from 94 a,to 99 ft, Diameter_ in. Slot alze,---,- in.from_A.to,_ft. Sand,gravel,some sill,brown/soft 1 20 Sand gravel,slit brown/soft 20 71 Sand/Filler packs O Yes ll Na Size ofpack material`_In. Send gravel,slit brown/soft,wb 71 100 Materials placed frnm�..S.to_n. Surface Stair !aJ Yes ❑No To what depth? 18 ft, Material treed In seal Bentonite Granular Did any airate contain unusable water? ❑Yes 11 Na Type ofwater? Depth of strata Method of sealing abate oft' Pump:btonufaclurer's Name N/A Type: H.P._, Pump intake depth:,__-ft. Designed flow rate:_gpnt Water Lovelss Land-surface elevation above mean sea level__ft. Stick-up oflop of well easing +1 ft above ground surface Stalin water level 57 f.below top of well Casing Data 10/10/2026 Artesian pressure-lbs.per square inch Dale Artesian vvmeris controlled by (cap,valvo,etc.) Well Tests. Was a pumping test perlbnrred?I1 No O Yes b by whom? Yield gpmwlth—a.drawdown alter,___,lire. Yield_____gpmwith_ft.drawdown after_his. Yield_gpm with . ft.ft.drawdown after...._..,.lire. Recovery date(lime=zero when pump is turned off—water level measured 6om well lop to water level) Time Water Load Time Water Level Time Water Level Data of pumping lost u Bailer test—gpnr with__ft.drawdown after lire. Air test 45 Spin with stern set at 97 ft.Pot 1 hrs, Date 10/1012025 Anaslan now•_gpnr Temperaluec of water_'F Was a chemical analysis Freda? ❑Yea l7 No Start Date 10/10/2025 Completed Date 10/10/2025 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for conslnuction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above ore true to my best knowledge and belief. O Driller❑Trainee O PE—Print Name Chris Jones Drilling Company Moerke&Bons Pump and Drilling Signature Address 1162 NW Slate Avenue License No. 2253 City,Stale,Zip Chehalls,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072N6 Dale 10/1312025 ECY 050.1.20(Rev I l/18) If you treed lids document Inca alternate format,please call the llrater Resources Program at 360.407.6872. Persons mlth hem Mg loss can call 711 for I1'aslrluglon Relay Service. Persons mirk aspeech disability can call 877-833-6311. MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST MATHEW WEEKS 10/30/2025 WELL SITE ADDRESS: 353 E SUNNY RD W, SHELTON WA 98584 Pump Make & Model: 1HP 15 Pump Set At: 80' Sounder Make & Model: WATERLINE Make&Model: MASTER Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 7621.5 57' 1 18 7639.5 58' 2 18 7657.5 58' 3 18 7675.7 58' 4 18 7693.4 58' 5 18 7711.6 58' 6 18 7729.4 58' 7 18 7747.6 58' 8 17 7765.8 59' 9 17 7782.8 60' 10 17 7872.7 60' 15 17 7962.3 60' 20 17 8052.4 60' 25 17 8142.6 60' 30 17 8232.8 60' 35 17 8322.4 60' 40 17 8412.5 60' RECOVERY 0 60' 1 58' 2 57' SIGNATUR ONS P AND DRILLING Vanguard Laboratory 2635Parkinon T.arie SW;Suite A k., •�t�l�irrlpl�WA 98502 v . . .360- 67-7010 (]N02111704 . COLIFORM.BACTERIA ANALYSIS FORM DateSampioCclleated The Sample Count 10 13~ /25 13Ml Monet ery Yoar pjPet ts°'n Type of Water System(oleo,only one box) IJ(croup A ❑Group B ❑Othet__2_f! Group A and Group B Systems—Provide from Water Fecltitles inventory(WF): lD8 Syatem Name: t.v (C}�1.6S "`. • , Contact Person: A,t 4.o rt o t .• DayPhane:{3(� ) �N$ �p Cal Phone:( Email: Eve.Phone:( ) $W foaft W.(PAI now,adSend ISt (Pdnt tul name,oddree end zip oodearo j moat—A-2 ---. 5 C1 ,5 ,UJ. `_- SAMPLE INFORMATION Samplecoaeded by(name): Specifle bcatlon where sample colle'c(ed: Special lnetmctlons or comments: 353 Fs+ WesV- i e114t1C/i1\1 We-. i C( Type of Sample(setae,only one type olsample boat types t through 6•below) 1.D Routine Dletdbutlon Sample(AIP) 2.O Itopeat Sampla(A P) Chbdnated:Yes. No ( dsbtouuon sybtem aaer onset roudne) i Unsnthfactoty mullne lab number: ChbdnaReslduaI Tole roe= 3.(around Vyetsr,tote Source Sample ` —"—•-`— — " Unsstbfadory roultne collectdate: S __ __a Chlorinated:Yes NQ_ 0 Triggered(AfP} Chbrine Residual:Total—_Free .D Aseesantent.(A!P) 4.Surfloo or OM Raw Source Water Sample(Enumenift) t I I t ❑E.Coy CI Few) FOAM Yes___.No- � o.❑Semple Golecled ror Informube Onty. LAB USE ONLY ORINKINOWAT£R RESULTS LAB USE ONLY Q UnaaNefactory Total CWNonn Present and Sallslactory ❑Eco8proaent ❑F.coiebsent f i BactorbiDenlsltyResuhs:TotatCoN(om _ Itoorrd,E,coJ1 /IDomf. FecatCobdam(..,. ' Ilooml, HPC It ml. Replacement Sample Required: ❑TNTC ❑Sample too old I ' ❑ Sample Voiume IJ damaged Conta►rrer U V?s tae r(erereme tfixr�6er d� ID -I O Sand D 1 MAWcoft q fa 236 Dale Hepoded to DOH tae tide ordr DOH tab,Sart 285- O3 (1O Kawut ay. wuraeanr r,n m one. 1 I ! Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 360-967--701O VAlrf30ARD t 1pbaar Nitrate/Nitrite Analysis Report Date Collected:(MM/DD/YY) r,f System Group Type:(Circle one.) A B Ot r: WaterSystem ID Number: _ System Name: Lab Number/Sample Number. 2 8 Ja . 9 1 0 County: Sample location 353 & - 6wnvu{ Wwds >Ld iUL4t Source Number(s) (List all sources if blended or composited) tov� Sample Purpose(check appropriate box) Date Received: (MM/DD/YY) ._L /1JJ.Z. 5 ❑ RC—Routlne/Compliance{Satisfies mortrtoring requirements.) Date Analyzed: (MM/DD/W) 1 k 3 J.J?1. ❑ C—Confirmation(Confirmation of chemical result.)' Date Reported: (MM/DD/Y'() J.—JO ,V 5 I ® i—Investigative(Does not sotis(ymonitoringrequirements.) COMMENTS: Q O--Other(Specify—does not satisfy rnonitoring requirements.) 7- "' 1 I Sample Composition(chuck appropriate box.) Sarnple'rype(Check one.) ❑Pre-triatment/Untreated(Raw) S—Single Source ❑Post-t'eatment(Finished) ❑ B—Blended(List source numbers in Source Numbers•field.) ❑Unknown or Other ❑ C—Composite(List source numbers in'Source Number?field.) Sample Collected by:(name) __ ❑ D—Distribution Sample Phone Number: . 3(,00 1L(fb R -6 Send Report to: Bill to:(Client name.) • iMft"Ig - 4- Sags \..dx a_. d- Sn,nc;_ diet mutt) Sha>r Avtr tlln2 )it) kAki AI, C4u�,toJ;.s w. q�5S t Analytical Results Data Exceeds MCI.? Method/ DOH N Contaminant Qualifier Results MRL SORE Trigger MCL Units (X If Yes) Initials _j 0020 Nitrate-N J J 1.39 j 0.5 0.5 I 5.0 I 10.0 i m Hech.10206 NOTES *Confirmation:Include the original lab number,sample number,and collection date of original sample in either comment section. --No trigger value for combined nitrate plus nitrite. Data Qualifier;A symbol or letter to denote additional information about the result, DOH#;Department assigned contaminant number. II Exceeds MCL(Maximum Contaminant Level):Marked if the contaminant amount exceeds the MCI under chapters 246-290 end 246- 291 WAC, if you have questions about this result please contact the department's drinking water regional office in your area, METHOD/INITIALS:Analytical method used/Initials of the analyst that performed the analysis. mg/L:milligrams per liter or parts per million. MRL(Method Reporting Limit):The lowest quantifiable concentration of a contaminant. S0RL(State Detection Reporting Limit);The minimum reportable detection of a contaminant as established by the department. Trigger:The department's drinking water response level,Systems with contaminants detected at concentrations at or above this level may be required to take additional samples or monitor more frequently. LAB COMMENTS Revised December 2021