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HomeMy WebLinkAboutWAT2026-00132 - WAT Application - 7/8/2026 WAT 2026-00132 MASON COUNTY 415 N.6�h Street & Shelton,WA 98584 Public HealthHuman Services air: Shelton:360-427-9670,Ext.400 Belf 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 mustaccompany this application. Part 1: Applicant/ Parcel Identification Name of Applicant: Scott Sanderson Date: 06/05/26 Mailing Address: 2261 Market Street,Suite 10301,San Francisco CA 94114 Phone: 332 222 7547 Parcel Number: 120313100000 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more l2f Building permit BLD2026-00493 connections) O Division of land: 9f Individual water source (one connection), #of Parcels? SPL d Well O Boundary line adjustment O Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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) ❑ 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. ❑ 1 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 Ed Water well report(attached to application). Depth 136 ft. Qf Well capacity Test(attached to application) 12 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. 1 Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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) R 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). Reviewer's Signatures: Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT oEPA RIM ENT OF Notice of Intent No. WE58854 ECOLOGYUnique Ecology Well ID'Tag No. 13OC093 Type of Work: State of Washington Construction Site Well Name(if more than one well): ❑Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: (1 Domestic O Industrial O Municipal Property Owner Name Peter Klein ❑Dewatering ❑Irrigation O Test Well O Other_____________ Well Street Address 470 E Camus Dr Construction Type: Method: City Shelton County Mason E"7 New well O Alteration O Driven O Jetted O Cable Tool O Deepening O Other O Dug i)Air- O Mud-Rotary Tax Parcel No. 12031-31-00000 Dimensions: Diameter ofboriag 6 in.,to 137 ft. Was a variance approved for this well? O Yes I]No Depth of completed well 136 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread (E 1 O 6 in. 0 132 .25 in. EN 1 ❑ i 1 O Location(see instructions on page 2): E3 WWM or❑EWM ❑ i ❑ in. _ in. O 1 O ❑ I O NE V-'Aofthe SW V4;Section 31 Townsltip 20N Range 1W ❑ 1 ❑ in. _ in. ❑ I O ❑ 1 ❑ Latitude(Example:47.12345) 47.17478 N ❑ I O in. _ - in. El ❑ ❑ 1 ❑ rr- Longitude(Example:-120.12345) -122.85922W Perforations: O Yes lE No Typo of perforator used Driller's Log/Construction or Decommission Procedure VNo.of perforations Size of perfomtiens_in by Formation:Describe by color,character,size of material and structure,and the kind and Perforated front ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: ©Yes ❑No ®K-Packer Depth 130 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire-wrapped Model No. Brown siltbound gravelly sand 0 8 Diameter 5" Slot size.01 S in.from 131 ft.to 136 R. Diameter— Slot size is from R.to ft. Brown silty fine to medium sand 8 29 Brown silty ravelt sand 29 39 2 Sand/Filter pack:O Yes 91 Mn Size of pack material in. 39 50 E Materials placed from a.to_ft. Gray fine to medium sand Gray sand and gravel,wet 50 65 L Surface Seal: 51 Yes O No To what depth? 18 ft. Gray silty,clay 65 74 D Material used in seal Bentonite chips 74 89 � Brown medium sand,dry Did any strata contain unusable water? O Yes O No L Brown sandy small to medium gravel,wet 89 104 a Type of water? Depth ofstmta Brown small to medium sand,some ravel,wale 104 121 Method of sealing strata off Brown medium sand,small to medium gravel, 121 Pump: Manufacturer's Name___________ Type: water 136 H.P. Pump intake depth: ft. Designed flow rate: gpm Brown silty sand and' ravel 136 137 Water Levels:Land-surface elevation above mean sea level 126 ft. C Stick-up of top of well casing JL.it,above ground surface Static water level......!L.ft,below top of well casing Date 3/18/25 i- Artesian pressure lbs.per square,inch Dato e Artesian water is controlled by (cap,valve,etc.) L o Well Tests: Was a pimping test performed? I No O Yes c > by whom? Yield gpm with_ft.dmwdown after ties. Yield gpm with____ft.drnvdown after bra. Yield gpm with_ft.dmwdown after_bra.hrs. aRecovery data(thue n zero when pump is tumed off—water level measured from well a top to water level) Time Water Level Time Water Level Time Water Level APR 02 202. ° WA State D@ part en 'o U u Date of pumping test o Bailer test gpm with_ft.dmwdown after lrs.} Air test 20 gpm with stem set at 120 it.for 1,5 hrs. Date 3118/25 E Artesian flow gpm oTemperature ofwater 50 °F Was aclremical analysis made? ❑Yes hi No Start Date 3/17/25 Completed Date 3/18/25 a. WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington we ll construction standards.Materials used and the information reported above are true to my best knowledge and belief. 5) 0 Driller 0 Trainee❑ Print Nam s Johnson Drilling Comp any Arcadia Drilling Inc. Si ature Address PO Box 1790 License No,3479 City,State,Zip Shelton WA 98584 IF TRAINEE:Sponsor's License o.2874 Contractor's Sponsor's Signature Registration No ARCADDI098KI Date 3118125 ECY 050-1-20(Rev 09/18) if you need this docwnest in air alter sale jonnat,please call the Water Resources Program at 360-407-6872. Persons with hearing loss call call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Peter Klein Well Tag#: BQC093 Site Address: 470 E Camus Dr, Shelton Depth: 136' Date of Test: 3/24/25 Static: 90.6' Pump Set: 120' TIME GPM LEVEL RECOVERY 1 Min 5 91.3 TIME LEVEL 2 Min 5 91.4 1 Min 90.6 3 Min 5 91.4 4 Min 5 91.4 5 Min 5 91.4 6 Min 5 91.4 7 Min 5 91.4 8 Min 5 91.4 9 Min 5 91.4 10 Min 8.5 91.4 15 Min 12 92.4 20 Min 12 92.7 25 Min 12 92.7 30 Min 12 92.7 35 Min 12 92.7 40 Min 12 92.7 45 Min 12 92.7 50 Min 12 92.7 55 Min 12 92.7 1 Hr 12 92.7 1 Hr 10 Min 12 92.7 Total Gallons Pumped: 713.5 V anguarct Lataoratcrry ,,.4 2635 Parkmont Lane SW,Suite A t)lyxrpta WA 98SU2 etiamsrAap 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected MASON 03/24/2025 3 Q 0 0 A, Month Day Year Type of Water System(check only one box) ❑GroupA ❑Group B ❑i Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: PETER KLEIN Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( } Email: Eve.Phone:( ) Send results:to:(Print full name,address and zip code ore-mail) II! arlete@arcadiadniling.comANDjenn@arcadiadisling.com SAMPLE lNF0RMATI{?fd Sample collected by(name):MA)( Specific location where sample collected: Special inshctions or comments: 470 E Camus Dr, Shelton Type of Simple(select only one typeof sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2.O Repeat Sample(NP) Chlorinated:Yes No (from distribution system after 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(NP) Chlorine Residual:Total_Free o Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E.coil ❑Fecal stared Yes._—No 5.Q Sample Collected for Information Only: LAB USE ONLY' DRINKING WATER RESULTS LAB USE ONLY O Unsatisfactory Total Coliform Present and '1 Satisfactory' O Ecolr present O€coif absent Bacterial Density Results:Total Coliform J100ml. Ecotr` /100mI. Fecal Coliform 11o0ml. HPC ll mi. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date ime Re ived; Lab Reference Number ReceiptTempC°: Method Code: SM9223B Date Reported'ta DOH Lab Use Only: DOH Lab-Sample# 285- 03259 DOH Fmna±"-313f8( cGypOr7)-tf 9vunro4Uus 3czgn irtan mtema3t�umat,calwoe2501I7 IT00RTYsa97:fy.