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HomeMy WebLinkAboutWAT2026 - WAT Application - 5/22/2026 WAT U2 MASON COUNTY 415 N.6'1 Street 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 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 7 Name on Applicant: f'7 8tIm , i.;,f/ l.r?L-? Date: Mailing Address: Phone: c5 t 0 ' O/ 1) 'C Parcel Number: 5 �r?7i S ` 17 t2oc2c7 Type of Water System Reason for Application _ ❑ Public/Community Water System (2 or more ; Building permit ��O O (.O`tO� connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment 0 Spring/surface water 0 Other(explain) 0 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 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 J:\EH Forms\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 1l Water well report(attached to application). Depth 166 ft. 06/29/2023 D( Well capacity Test(attached to application) 3.8 - 27.5 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. 07/10/2023 Q Satisfactory bacteriological test within last year(attach to application). 04/24/2026 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 A Part-3: Mason County Community Services Evaluation (staff use only) i( 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). EH APPROVED Reviewer's Signatures: Environ. Health: Anderson ,5/22/2026 Date 05/22/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 3aO55000O� r WATER WELL REPORT r DEPARTMENT OF Notice of Intent WE49804. ECOLOGY Unique Ecology Well ID Tag No, BPF019 Type of Work: State of Washington IE Construction Site Well Name(if more than one well): ❑ Decommission . Original installa►ion NOt No. Water Right Permit/Certiftcate.No. Proposed Use: 17 Domestic d Industrial O Municipal Property Owner Name Kevin Ballowe 0 Dewatering ❑irrigation ❑Test Well 0 Other %Veil Street Address 51 SE Lagoon Lane Construction.Type: Method: City Shelton County Mason Al New well ❑Alteration 0 Driven O)etted ❑Cable Tool O Deepening O Other 0 Dug f,I Air- D Mud-Rotary Tax Parcel No. 32025-50-00007 Dimensions: Diameter of boring 6 in.,to 175 ft. Was a variance approved for this well? ❑Yes ©No Depth of completed well 166 ft. If yes,what was the variance:for? Construction Details: Wall Casing Liner'Diameter Front To Thickness Steel PVC Welded Thread (9 I ❑ .L_._in. t) 663 .025 in. 13 I O © I O Location(see.instruc(ions on page 2): .©W WM or❑EWM O I O in, _ in, 0 I ❑ 0 I. O NE '/,'/iofthc NE '/+;Section .25 Township 2t)N' Range 3W ❑ I O ,in, — — 1 in, ❑ ❑ ❑ I D p ) O in in. ❑ I ❑ ❑ � ❑ Latitude(Example:41.12345),47.193611 Longitude(Example:-120.12345) -122.991893' Perforations: D Yes lid No T}peofperfoeator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations_in.by - in. Formation:Describe'by color,character,size of material and structure,and the kind and Perforated from ft.to ,.,,ft,below ground surface naturo of the material in each layer penetrated,with at least one entry for each of Screens: O Yes 0 No GI K-Packer C ) Depth 160 ft. information. Use additional sheets if necessary, Manufactucer'sNatne Alloy Machine Works Material From To Type Stainless Slotted Model No. silt loam 0 6 Diameter 5° Slot size.cl2 in:front 161 ft.to Brown 166 fl. 6 6 Diameter Slot size_in.from _ft.to-ft, Brown silty day 12 Brown medium sand,gravel,silly 12 21 Sand/Filter pack:(J Yes 1 No Size of pack material_ _in. Gray silty clay 21 56 Materials placed from-ft.to_,._ft, Gray silt 58 70 SuifaceSeal: Sl Yes ON! To what depth?'18 ft, Dark brown peat 70 74 .Material used in seal Bentorite Chips Gray sticky clay 74 106 Did•any strata contain unusable water? ❑Yes E7 No. Gray Stick Cla 1.06 108 Typo of water? Depth of strata Method of sealing strata oIP Black silty sand and gravel 108 136 Gray fine sand,some gravel 138 148 Pump:'Manufacturer'sNanle Type Gray silty clay 148 153 HP. Pnmp intake depth:_ft. Designed now rate: gum Black gravel,sand,loose,water 153 166 �ValerLevels: Land-surface elevation above mean sea level 144 ft. Blackfinesand,.some. ravel,silt 166 175 Stick-up of top ofwell casing.....L.ft.above ground surface Static water level 130 ft,below top of well casing Date 6/29123 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumpingteslperfa rated? R1 No. O Yes t byt,hom? Yield gptp with ft.drawdown after tus. 'Yield gpm with_ft.drawdown after his. 3 Yield gpni with_ft,drawdown after_her. lkecovrrydata(time=zero when pump is turned off—dater level measured front well top to water level) Time WaterLevel Time Water Level Time Water Level Date of pumping test bailer test gpm with_ft.drawdown afteru hrs. Air test 20 gpmi with stem set at J.40 ft.for._L.....his, Date 6/2923 Artesian7low gpus Temperature of water 51 .°F Was a chemical analysis made? ❑Yes 91 No Start Date 6/26/23 Completed Date 6/29/23 S.\ELI CONSTRUCTION CFI1TIFiCATION: I constnicted'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, i11 Driller O Trainee O P—Print Name h Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No, 287:4 City State Lip Shelton WA 96584 iF TRAINEE:'Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 6/29/23 ECY 050-1-20.(Rev 09113) lf),oir need this document is an alternate formal,please call Ilse Water Resources Program at 360-407-6872. Persons}rich hearing loss can call 711 for Washington Relay Service. Persons vrilli a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.Q. Box 1790 Shelton,WA.98584 Customer: Kevin Ballowe Well Tag#: BPF019 Phone: (360)301-9173 Depth: 166' Well Site Address: 51 SE Lagoon Lane,Shelton Pump Set: 141' Date of Test: 7110/2023 Static 11.9' TIME GPM LEVEL RECOVERY I Min 3.8 119.0 TIME LEVEL 2 Min 3.8 119.2 1 Min 121.0 3 Min 3.8 119.5 2 Min 120.1. .4 Min 3.8 119.5 3 Min 120.0 5,Min 3.8 119.6 4 Min 119.8 '6 Min 13.0 '119.6 5 Min 119.6 7 Min 13.0 121.0 6 Min 119.4 8Min 13.0 121.0_ 7Min 119.3 9 Min 13.0 121.0 8 Min 119.2 10 Min 16.6 121.0 9 Min 119.1 15 Min 16:6 121.9 10 Min 119.0 20 Min 20.0 122.0 25 Min 20.0 122.7 30 Min 20.0 122.7 35 Min 20.0 123.0 40 Min 27.0 122.6 45 Min 27.5 123.7 50 Min 27.5 125.1 55 Min 27.5 127.2 1 Wr 27.5 127.2 APR s Iaborato Bt 2635 Parkmant Lane SW,Suite A Olympia WA 98502 *l�irey�pTt �lM9T7�Orl�Q , COLIFORM BACTERIA ANALYSIS FORM t4 ZL/ r 2/e L;yv l4 a'$07J Type of Water System(chedt only one box) r p Group A ❑Group B Iher Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): log Sysfern Contact Person: W h (3 ) Cell Phone: ) Email: Eve.Phone:( S' A e is b Print Aft name;address and zp coi)e or a mazy �VI_r2. h���olA�e e__� 7 C119f t Gt�!27. SAMPLE INFORMATION Sahip"ecolrected-by=namer VI A p'`S lac `s8 calla,1 Special instructions or comments: Type of Sample(selec only one type of s pie from types I through 5 below) 1.❑Routine Distribution Sample(AlP) 2.❑ Repeat Sample(NP) Chlorinated:Yes .No (from distnbtt'on sysrem after inset routine) ,Unsatisfactory routine lab number. Chlorine ResldualJblat•_Free___ 3.Ground Water Rule Source Sample Unsatisfactory routine cotect date:S f I Chlorinated:Yes No ❑Triggered(AIP) Chlorine Residual:Total free— ❑Assessment(NP) 4. Surface orOWl Raw Source Water Sample(Enumeration) I ❑E.ouR ❑Fecal Fod Yes_no____ �. Sony a Ca'ectetl,tor lnronnatlon Only: LAB USE ONLY 'DRINKING WATER RESULTS LAB USE ONLY Q Unsatisfactory Total Coliform Present and (J Satisfactory 0 E,coRpresenl ❑Ecotiabsenl Bacterial Density Results:TotalColiform G1.0 I100ml. Eco5 <1•0 I100ml. FecalCotKarm /1D0ml, HPC t1 mi. Replacement Sample Required: 0 TNTC 0 Sample too old ❑Sample Volume ❑Damaged Container ❑. Datertrme Revel ed: Lab ReGuence Rattier 4/24/2026 \/2 ol -�9 RecerptTempC': Me COdQSM9223B Date Reported b DOH Lab UseOmy: DOH t sarrp!e& 285- W�Lll` n; ta++nomwtr•susra we 2sattrptxrrnwnrr ns1 ad filet ptr n:s rime 6�n9,9 ';AitSaY'S!