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HomeMy WebLinkAboutWAT2026-00077 - WAT Application - 6/15/2026 WAT 2026-00077 MASON COUNTY 415 N.6'h Street. t Shelton,WA 98584 Public Health & Human Services Shelton:360-427-9670,Ext.400 Beltair:36U-275-4.467,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.. , Anapprdvèdbiiilding site•" iari must,'accoman this-a" lication Part 1: Applicant/ Parcel Identification �Name of Applicant: ,Iwpnmh. lac t , O \ Date: 1 J/`/1Z , Mailing Address: Z/3 S 1(W , + Ceiliisz a,3NA Phone: j�}-(� _ he ' Parcel Number: Z Z OZ 7 5 WOOI L Type of Water System Reason for Application O Public/Community Water System (2 or more Building permit connections) ❑ Division of land: if Individual water source (one connection), #of Parcels? SPL El Well ❑ Boundary line adjustment O Spring/surface water s O Other(explain) O Other(explain) O 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) 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. Ii 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 oft Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well El Water well report(attached to application). Depth 2 7C1 ft. >400 Well capacity Test(attached to application). J[) 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. 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) 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 approvalindicates requirements of Sanitary,Code,Title 6 Chapter 6.68040-Determination ofs Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW Li Unsatisfactory Determination Applicant's water supply does not appear adequate to meet the needs of its intended,use for the following reason(s). Fl Reviewer's Signatures:` 6/15726. Environ. Health: Date This form may be scanned and available for public view at www.masoncountvwa.gov Page 2 of 2 WATER WELL REPORT Notice of Intent No. WE58949 ODEPARTMENTOFECOLOGY Unique Ecology Well ID Tag No. BRR 101 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission b Original installation NO!No. Water Right Permit7Certificate No. Proposed Use: ❑Domestic 0 industrial ❑Municipal Property Owner Name Lexar Homes ❑Dewetering 0 irrigation ❑'Pest Well ❑Other Well Street Address SE Arcadia Rd Construction 1'ype: Metlnnlp City Shelton County Mason Q New well ❑Alteration ❑Driven ❑Jetted 0 Cable Tool ❑Deepening ❑Other ❑Dug ll Air- 0 Mud-Rotary Tax Parcel No. 22028-75-90012 Dimensions: Diameter of boring 6 in.,to 280 R. Was a variance approved for this well? ❑Yes il No Depth ofcompleted well 279 ft. Construction Details: Wall If yes,what was the variance for? Casing Litter Diameter From To Thickness Steel PVC Welded Thread © ❑ 6 in. +1 274 .25 itt. Q I ❑ ❑ I ❑ Location(see instructions on page 2): ©WWM or 0 EWM ❑ I ❑ in. , in, ❑ I ❑ 0 I 0 SE ''/a-'/n of the NE %a;Section 29 Township 20N Range 20 ❑ I ❑ in. — — m. ❑ I ❑ 13 13 Latitude(Example:47.12345) 47.19582 ❑ I ❑ in. , in. ❑ I ❑ ❑ I ❑ Longitude(Example;-120.12345) -122.95431 Perforations: ❑Yes 17 No Typo of perforator used Driller's Log/Construction or Decommission Procedure N .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 sudhce nature of the material in each layer penetrated,with at least one entry for each change of Screens: ll Yes ❑No no K-Pucker r--=,r Depth 273 A. information. Use additional sheets ifnecessmy. Manufacturer's Name Johnson Material From To Type Stainless Steel Model No. Top Solt 0 1 Diamacr 5 in. Slot size .018 in.from 274 ft.to 279 A. 11 Diameter_ in. Slot size- in.from-ft.to_A. Clay,silt,sand,gravel,brown/soft 1 Sand,gravel,silt,brown/soft 11 20 SandlFilter pack:❑Yes ❑+No Size of pack material_in, Sand,silt,brown/soft 20 29 Materials placed from. ._ft.to-ft. Sand,silt,tine,gray/soft 29 52 Surface Scott l7 Yes O No To what depth? 18 It. Clay,gray/hard 52 68 Material used in sent B sntonite Chips Sand,silt,fine,brown/soft fi8 90 Did any strata contain unusable water? ❑Yes ©No Sand,silt,fine,gray/soft 90 108 Type of water? Depth ofstrata Method ofsenting strata off Sand,clay, rayfltard 108 149 Sand,gravel,slit,some clay,gray/hard 149 190 Ptunp: Manufacturer's Name N/A Type: Sand,Silt,clay,gray/hard 190 209 H.P._ Pinup intake depth;_ ft. Designed flow rate: gpm Sand,gravel,silt,some clay,gray/hard 209 215 Water Levels: Land-surface elevation above mean sea level_A. Sand,slit,gray/hard 215 245 Stick-up of top of well casing +1 ft.above ground surface Sand,gravel,silt,little water,graylhard 245 272 Static water level. . . below top of well casing Date 3124/2025 Sand,gravel,silt, gray/hard, wb 272 280 Artesian pressure^lbs.per square inch Date Artesian water is controlled by (cup,valve,eta.) Well Tests: Was a pumping test performed? ❑N No ❑Yes by whom? Yield gpm with_ft.drawdown after_hrs. Yield T gpm with,._ft.drawdown after firs. Yield gpm with—ft.drawdown after hrs. Recovery data(tine=zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Witter Level Data of pumping test Bailor test—glint with,A.drawdown after,_,_,lies. Air test 30 gpm with stem set at 277 ft.for.....j..........bra, Date 3/2412025 Artesian flow glint Temperature of water_"F Was a chemical analysis made? ❑Yes ❑O No Start Date 3/21/2025 Completed Date 3/24/2025 WELL CONSTRUCTION CERTIFICATION: I constructed 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. 11 Driller L7 Trainee❑PE—Print Name Chris Jones Drilling Company Moe rke&Sons Pump and Drilling Signature Address 1162 NW State Avenue LicenseNo. 2253 , City,State,Zip Chehalis WA 98532 IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature Regislrttion No. MOERKSPO72N5 Date 3/25/2025 ECY 050-1-20(Rev 11/18) Ifyou need this dociatteul in an alternate formal,please call the Wale).Resources Program al 360-407-6872. Persons ivith hearing loss can call 711 for Washington Relay Service. Persons with a speech disabilify can call 877-833-6341, 1 V f Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY Collected:by: Moerke and Sons Matrix Drinking Water 360-748-3805 Laboratory ID: V250402-17 Sampling Address: Date Sampled:4/2/25 13:00 SE Arcadia Road Lot#2 Date Received:4/2/25 15:10 Shelton,WA 98584 Date Reported:4/4/2025 Sample ID: SE Arcadia Road Lot#2 Analysis Result SDRL .MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V250402-17 Analyst:AF Coliform,Total Negative 1 1 MPNI100 mL 1 4/2/25 16:48 E.coli Negative I I MPN/100 mL 1 4/2/2516:48 Nitrate by Hach Method 10206 Batch 1D:V.250402-17 Analyse:KS Nitrate(as N) ND 0.50 10.00 mg/L 1 4/2/25 17:00 Notes: NIPNi Most Probable Number ppm:pans per million ad:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/04/2025 n/a:not applicable - -- SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 04/04/2025. DF:.Dilution Factor 1T025r2017 ITED MCL:Maximum Contaminant Level 07025: rwnonAToav Samples were received in acceptable condition.The results in this report relate onl to theportion of the sample(s)tested.All analyses were performed consistent' P P O� P Y Y with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 testing@vanguat:dlaboratoty.com www.vanguardlaboratoty.com 1 of l 1