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HomeMy WebLinkAboutWAT2026-0009 - WAT Application - 6/5/2026 415 lei.6`°'5trwt Sheiton,WA 98584 Sheittm:36o.427-9670 Ext,400 isHealth & HumanServices !3clfair:36O-2754467J4OO_ Application for Determination of Water Adequacy Instructions 1. Corriplete.Part 1; No determination can be.made,until Part;1„is ful_ v corn lewd 'a: 2n Complete only the portion of Part 2 applying to the typeof water connection utilized Submit competed application with any required attachments for review 47 An approved btlilifin 'site plan`must accOm art `Ellis application. Part 1: Applicant/ Parcel Identification Name of Applicant: `>t Gt`n 1c n -, Date: ! / `Mailing Address: r j '�" . ' Li __ _ Phone: Parcel Number: Type of Water System Reason,for Application 0 Public/Community Water System(2 or more E3" Building permit connections) CI Division of land: iI Individual water source(one connection), #of Parcels? SPL Well 0 Boundary line adjustment,: 0 Spring/surface water ' O 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 PubliclCommunity Water signature required) , System box. Part 2: Water Connection Information p Complete the section appropriate for the type of water connection being evaluated Public Water System Name of Water System: Water Faculty inventory(W l)Number (write"none'`for two-party). 0 F lam the-manager of thiis'water'systerr►.The water system has been approved for ' services, There are presently ' connection(s)in use.This will be the connection. E1 I am the manager of this system.This connection will be to upgrade'or change'the 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.masoncoun a.oty J"J H Forms\Drinking Water Revisui 051013/2024 PAW 1 of 2 Group 8 Water Systems 'Satisfactory bacteriological test within last year(attach to application). individual Water Well 9z wvtL ltd t ! Water well report(attached to application). Depth ft. 10-23 l Well capacity Test(attached to application) 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. Satisfactory bacteriological test within last year(attach,to application).., Individual Spring/Surface Water . 0 WDOE permit(attach to application) O Method of disinfection O 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 Dates Relationship to Applicant Part 3: Mason County Community Services Evaluation (staff use only) i 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. 0 Unsatisfactory Determination: Applicant's watersupply does not,appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date. This form may be scanned and available for public view at www.masoncount4wa.gov ,. . Mtge2cf2 WATER WELL REPORT DEPARTMENT OF Notice of latent No. WE60915 ECOLOGY Unique Ecology Well ID Tag No,130C188 Type of Works State of Washington 0 Construction Site Well Name(if more than one well): O Decommission b driginal installation NOI No. Water Right Permit/Certiiicate No_ Proposed Use: L l Domestic 0 Industrial 0 municipal Property Owner Name Jessica gloom 0 Dewateriag O ttrigetion 0 Test Well 0 Other Well Street Address 271 E Big Skookum Rd Coastruction Type:, Method: IE New well 0 Alteration 0 Driven 13Jetted 0 Cubic Tool City Shelton County Mason 0 Deepening 0 Other ❑Dug GI Air- ❑Mud-Rotary Tax Parcel No. 22020-75-90103 Dimensions: Diameter of boring_6 in.,to 157 ft. Was a variance approved for this well? O Yes 1 No Depth of completed well 157 ft. If yes,ivhat was the variance for? Construction Desalts: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread R I O 6 in: a 1L. .25 in. t 10 O I Location(see instructions on page 2): t WWMor O EWM O I -0 in, _ _ SE V t of the NE i%',Section 20 Township 20N Range...2!L Latitude(Example:47.12345) 47.20827 N o in. in. 0 i 0 0 ( 0 Longitude(Example;-120.12345} -122.95571°W Perforations: ❑Yes I@ No Type of perforator used , No.of perforations size of perforations_in.by_in. Drillers LoglConstrnetize or Deeatnmission Procedure Perforated from_ft:to ft.below ground surface Formation:Describe by color,character,size.of withamaterial and structure and the kind and nature of the material in each layer penetrated with at toast one entry for each change of Screens: tt7 Yes 0 No 91 K-Packer Depth 151 ft, information. Use additional sheets if necessary. Manufacturer's Noma Alloy Machine Works. Material From To Type Stainless slotted Model No. Diameter S_ Slot size.020 in.from 152 ft,to 157 ft, Brown slltyfinesand 0 6 Diameter— Slot size__in.from _ft.to_ft. Brown silty sand,gravel,loose 5 28 Brown silty sand,gravel 26 45 Sand/Filter pack:O Yes li No Size of pack material in. Materials placed from.—ft.to ft. Gray silty clay,sand,gravel 45` -92 Gray silty sand,gravel wet 92 109 Surface Seat, 81 Yes' 0 No To what depth? 18 ft. Gray sand,multi-colored gravel,water,low static •109 127 Material used in seat Bentonite chips Gray all clay 127 134 Did any strata contain unusable water? 0 Yes fi7 No Type ofwaM? Depth ofstrata Multi-colored ravel, ra sand,water 134 157 Method of sealing strata off Pump, Manufacturer's Name Type: }EP. Pump intake depth:—ft. Designed flow mtc:—gpm Water Levels:Land-surface elevation above mean sea level 118 ft, Stick-up of top 01'well casing 1,_8 ft.above ground surface Static.water cvel e9 fl,below top,of well casing Date 9122125 Artesian pressure_lbs:per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? M No '0 Yes by whom? Yield—gpm with_„__ft.drawdown after—hrs. Yield—gpm with_ft.dmwdown alter_hrs. Yield—gpm with—ft.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 Baiter seat_gpm with—ft.drawdown after_his. Air test 35 gpm with stem sit atgpun with stem set at j4Q, ft.for j,,,.,,.,,his Date 9/22/25 Artesian flow__gpen Temperature ofwater 50 °F Was a chemical,analysis made? 0 Yes ®No Start Date 9118125 Completed Date 9122125 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materialsused and the information reported above are true to my best knowledge and belief, O Driller( Trai O PE—Pri me James Johnson Drilling Company Arcadia Drilling Inc.. Signature Address PO Box 1790 License No. 791 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No;2874 Contractor's Sponsor's Signature Registration No.ARCADDI098KI Date 9/22/25 ECY 050-1-20(Rev 09/18) lf}ou need this document in an ahernareformar,please call the Water Resources Program at 3 60407-6872. Persons with hearing loss can call 711,/or Washington Relay Senire. Persons with a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Jessica Bloom Well Tag#: BQC188 Site Address: 271 E Big Skookum Rd,Shelton Depth: 157' Date of Test: 5/28/26 Static: 87.4' Pump Set: 145' TIME GPM LEVEL RECOVERY 1 Min 10 87.9 TIME LEVEL 2 Min 10 88.5 1 Min 88.3 3 Min 10 89.8 2 Min 88 4 Min 10 89.9 3 Min 87.5 5 Min 10 90 4 Min 87.4 6 Min 10 90 7 Min 10 90 8 Min 10 90 9 Min 10 90 10 Min 23 90 15 Min 23 95.7 20 Min 21.5 96 25 Min 21.5 95.7 30 Min 21.5 96 35 Min 21.5 96 40 Min 21.5 96 45 Min 21.5 96 50 Min 21.5 96 55 Min 21.5 96 1 Hr 21.5 96 1 Hr 10 Min 21.5 96 Total Gallons Pumped: 1502.5 gallons Vanguard Laboratory -2635 EarkmontLane SW,Suite A Qlynnpia.WA 98502 �r rcra a 360-96`1-701'0 COLIFORM BACTERIA ANALYSIS''FORM` Date Sample Collected Time Sample County Collected Mason 0512812026. DAM Manih O,ay Yep - _ j l PM Type of Water System(check only one box) ❑Group A ❑Group B 9 Other Group A and Group 6 Systems-Provide from Water Facilities Inventory(WFI);. ID# System Name: JeS51Ca BIOom Contact Person:Arcadia Drilling,Inc Day.Phone:(360 )426-3395 Cell Phone:( Email: Eve:Phone:( ) Send;resulis)Q(Print full name,address and zip code•or e-mail) adeta@arcadiaddtiing.corrrANDTenn@arcadiaddiling.com SAMPLEINEORMATION Sample collected by(name):Shad Specific location where sample collected: Special instructions or comments: B00188-271 E ft.Skookum'Rd�Shelton, Counts please ,Typeof Saimpie'(select only one type of sarilpie from typt s 1 lhratgft 5 below) 1.❑.Routine Distribution Sample(AlP) 2.O Repeat Sample(AIP). Chlorinated:Yes No (from disUlbution system alter unsat.routine) • Unsatisfactory routine lab number. Chlorine Residual:Total___Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S I I Chlorinated:Yes No ❑Triggered(A!P) Chlorine Residual:Total_Free ❑Assessment(A/P) 4. Surface or GWIRaw Source Water Sample(Enumeration) ❑E.coil O Fecal FNsred Yos_No� 5.©Sample Collected for Information Only: IAB.USE ONLY DRINKING WATER,RESULTS, LAB USEONLYF ❑Unsatisfactory Total Coliform.Present and Satisfactory ❑£.00lipresent ❑E:coliabsent Bacterial Density Results:Total Colifonn<1 .0 I100ml. E.coi<1.0 Y100ml. Fecal Coliform t100ml. HPC /1 ml. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume O Damaged Container O oatelrme Receivcid:5/29/2026 Lab Reference Number Receipt Temp C': MethodCode: SM9223B Date Reported to DOH Lab Use Onlyr DOH Lab-Sample# 1123 Z 6otiFart e313r9t eciui-Irani d≥ wrar ta?Hlc rnau.rznaRr rrco ry ar in). TEds vN.oCY,�9citia�s ae avadzL?eatawr.dwl.arayvkk:,rlsgwtm,