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HomeMy WebLinkAboutWAT2026-00102-WATER ADEQUACY - WAT Application - 6/17/2026 WAT 2026-00102 MASON U T415 'Street Shelton,WA 98584 �y , Shelton:360-427-9670,Ext.400 Public Health & Human Services Belfair:360-275-4467,Ext 400 Application for Determination of Water Adequacy Instructions I Complete Part 1. No determination cart 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 appróvedbuIldin site plan must accompanyan this application. Part 1: Applicant/ Parcel Identification aa Name of Applicant: 4I Jate: G)96(71" Mailing Address: 2 0G-, ® Phone: ) 1U-O5 ,3 "ej-) Parcel Number: t� C Vi9%L_tt0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit BLD2026-00436 connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPl_ [ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ 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) ❑ l 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. ❑ 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 114 Water well report(attached to application). Depth ft.' l5d Well capacity Test(attached to application) 6.5-15 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. lI 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) S1 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 water supply does not appear adequate to meet the needs of its Intended use for the following • reason(s). Reviewer's Signatures: iunW- t 6/17/26 Environ. Health: r Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT cam.' ' DEPARTMENT OF Notice of Intent No. WE45551 ECOLOGY Unique Ecology Well ID Tag No. BNXI60 Type of Work: State of Washington IN Construction Site Well Name(if more than one well): O Decommission Original installation NOI No. Water Right Pennit/Certificate No. Proposed Use: On Domestic O Industrial O Municipal Property Owner Name Greg McFarland O Dewatering O irrigation O Test Well O Other Well Street Address 250 E Lombard Road N Construction Type: Method: City Grapeview County Mason ©New well O Alteration O Driven O Jetted O Cable Tool �' O Deepening O Other O Dug i l Air- O Mud-Rotary Tax Parcel No. 12107-14-00110 Dimensions: Diameter ofboring 6 in.,to 114 ft. Was a variance approved for this well? ❑Yes N No Depth of completed well 114 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 1 O 6 in. 0 106 0.25 in. o I O O I ❑ Location(see instructions on page 2): l3 WWM or O EWM o O in. — in, O I O O I O SE 'h-¼of the NE ¼;Section 7 Township 11!L Range JiLW ❑ I ❑ in. _ in. ❑ I ❑ DID ❑ i ❑ in. — in. ❑ ❑ ❑ I O Latitude(Example:47.12345) 47.323248 Longitude(Example:-120.12345) -122.848864 Perforations: O Yes ❑O No Type of perforator used Drillers Log/Construction or Decommission Procedure No.of perforations_ Size ofperforations_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 nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes ❑No 91 K-Packer b Depth 103 tt information. Use additional sheets if necessary. Manufacturer's Name Alloy Machines Works Material Front To Type Stainless Slotted Model No. Brown silty sand&gravel,loose 0 5 Diameter 5- Slot size.020 in.from 104 ft.to 109 ft. Diameter 5" Slot size.010 in.from 109 ft.to 1114 fl. Brown silty sand&gravel 5 15 Brown medium sand,some gravel 15 29 Snnd/Filter pack:O Yes I3 No Size of pack material_in. Brown silty sand,tight 29 32 Materials placed from_ft.to-It. Brown silty sand&gravel 32 45 Surface Seal: 91 Yes O No To what depth? 19 ft. Multicolored gravel,fine brown sand,silt 45 76 Matcrial.used in seal Bentonite Chips Brown silty sand&gravel,wet 76 92 Did any strata contain unusable water? O Yes KI No Type of water? Depth of strata Brown fine to medium sand,gravel loose,water 92 112 Method of sealing strata off Gray silty clay 112 114 Pump: Manufacturer's Name Type: H.P._ Pump intake depth:_ft. Designed flow rate;_gpm Water Levels: Land-surface elevation above mean sea level 200 it. Stick-up of top of well casing 1_5 ft.above ground surlacc Static water level 58 ft,below top of well easing Date 9/9/2021 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? O No O Yes r-� by whom? Yield gpm with_ft.drawdown after_Itrs. Yield_gpm with_ft.drawdowa after_hrs. Yield_gpm with—ft.drawdown after_hrs. Recovery data(time=zero when pump is turned off—water level measured front well top to water level) Time Water Level rime Water Level Time Water Level Date ofpsinpiug test Bailer test!gpm with_ft.drawdown after_hrs. Air lest 20 gent with stem set at 90 ft.for 1 hrs. Date 9/9/2021 Artesian flow_gpm Temperature of water 48 °F Was a chemical analysis made? ❑Yes ❑No Start Date 9/9/2021 Completed Date 9/9/2021 WELL CONSTRUCTION CERTIFICATION: 1 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. El Driller O Trainee O PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No 2874 City,State Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 9/10/2021 ECY 050-1-20(Rev 09/18) Ifyou need this document in an alternate format,please call the Water Resources Program at 360-4'•07-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-63)1. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Greg McFarland Well Tag#: BNX160 Phone: 360-620-5232 Depth: 114' Well Site Address: 250 E Lombard Rd N Pump Set: 100' Date of Test: 9/13/2021 Static: 58.90' TIME GPM LEVEL RECOVERY 1 Min 6.5 61.5 TIME LEVEL 2 Min 62.9 1 Min 62.9 3 Min 63.3 2 Min 60.1 4 Min 63.7 3 Min 59.3 5 Min 63.7 4 Min 58.9 6 Min 63.7 5 Min 7 Min 12 63.7 6 Min 8 Min 66.1 7 Min 9 Min 67.1 8 Min 10 Min 67.2 9 Min 15 Min - 67.5 10 Min 20 Min 15 67.6 11 Min 25 Min 70 12 Min 30 Min 70 13 Min 35 Min 70 14 Min 40 Min 70 15 Min 45 Min 70 16 Min 50 Min 70 17 Min 55 Min 70 18 Min 1•Hr 70 19 Mn 1 Hr 10 Min 20 Min 1 Hr20 Min 21 Min 1 Hr 30 Min 22 Min 1 Hr 40 Min 23 Min 1 Hr 50 Min 24 Min 2 Hr 25 Min 2 Hr 10 Min 26 Min 2 Hr 20 Min 27 Min 2Hr30Min 28 Min 2 Hr 40 Min 29 Min 2 Hr 50 Min 30 Min 3 Hr 3Hr 10 Min 3 Hr 20 Min 3 Hr 30 Min 3 Hr 40 Min 3 Hr 50 Min 4 Hr Thurston County Environmental Health 412 Lilly Rd NE•Olympia,WA 985O6 360 867-2631 TRUEi3110N COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County 5 1 J 2( Collected o a c h Month Day Year Type of Water System(check only one box) Private Household ❑Group A ❑Group B 0 Other Group A end Group B Systems—Provide from Water Facilities Inventory(WFI): ID# { System Name: Contact Person: k1vfr McFcZptand Day Phone:( ( O 7D.0 S I Cell Phone:( ) E-mail: f e:( ) Send results to:(Pilot fu name,address and zip code or email address) SAMPLE INFORMATION Sample collected by(name);ff� fl �!C i2 plan€ Specific location or address where sample collected: � Special Instructions or comments: 2so E Lom ha►4 Kd N 6v& %AW a 2 !NN Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unset.routine) Chlorinated:Yea No ❑Distribution System Chlorine Residual:Total_Free__, Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total_Free— ❑E.coil—GWR(NP) ❑Fecal—surface,owl.spdnaa(numeration) Unsatisfactory routine lab number: Flitered:Yes_No. _ ❑Assessment Monitoring(NP) Unsatisfactory routine collect date: ❑other _^___I S 4. ample Collected for Information Only Investigative Construction/Repalra— Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Conform Present and ®Satisfactory ❑Ecoll present 0 E.coll absent No Coliform detected Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform 1100mi. Ecoll 1100ml. Fecal Colifonr>_ I100ml Enterococcl J1O0 ml. Method Code:®SM 9223B ❑SM 9222D Date and Time Received: 0 SM 9216B 0 Enterolert® 5/8/2026 Date and Time Analyzed: Date Reported: SempteNum (00Hnumberplustivedictla) Lab Use Only: 0 8 0 50828 O.�c( LID b4 DOH Formtt337a9(rev:s 1123) /���`��j ^^