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HomeMy WebLinkAboutWAT2025-00243 - WAT Application - 7/8/2026 (2) WAT 2025-00243 415 N.6th Street , J I 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 off 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 Name of Applicant: REESE ET VIR KATHRYN Date: 7/8/2026 Mailing Address: PO BOX 1790 Phone: 208-410-7237 Parcel Number: 319142400020 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more I Building permit BLD2025-01328 connections) 0 Division of land: l Individual water source (one connection), #of Parcels? SPL l Well 0 Boundary line adjustment 0 Spring/surface water 0 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) ❑ 1 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 I Water well report(attached to application). Depth 159 ft. ll Well capacity Test(attached to application) 11-25 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. I 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) Cx 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:. • . ; 7/8/2026 Environ. Health. Date This form may be scanned and available for public view at www.masoncountywa.gv Page 2 of 2 WATER WELL REPORT . DEPA tMc.N ©` Notice oflntentNo. WE58706 ECOLOGY Unique Ecology Well ID Tag No. BQC134 Type of Worlc State of Washington 1 Construction Site Well Name(if more than one well): O Decommission b Original installation NOI No. Water Right Permjt/Certificate No. Proposed Use: 91 Domestic ❑Industrial 0 Municipal Property Owner Name Kathryn Reese 0 Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 897 SE Dahman Rd Construction Type: Method: CityShelton County Mason J New well L Alteration 0 Driven ❑Jetted ❑Cable Toot ❑Deepening ❑Other U Dug d Air- C Mud-Rotary Tax Parcel No. 31914-24-00020 Dimensions: Diameter of boring 6 in.,to 160 ft Was a variance approved for this well? O Yes 0 No Depth of completed well 159.5 ft, If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread [! ( O 6 in. O 154.5 -25 in. a 1 0 Ll 1 0 Location(see instructions on page 2): t r WWM or❑EWM C. 1 ❑ in. in. 0 1 0 O 1 0 NW '!y of the NE '!s;Section 14 Township J2i.Range 3W ❑ ❑ in. in. ❑ ❑ ] ❑ Latitude(Example:47 12,4)) 47.13605 N 1 ❑ in. in. ❑ ❑ ❑ I ❑ Longitude(Example:-120.12345) -123.02232W Perforations: 0 Yes d!-1 No Type of perforator 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 nature of the material in each layer penetrated,with at least one entry for each change of Screens: D Yes 0 No N)K-Packer . Depth 1515=.5 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5O Slot size.020 in.from 154.5 ft.to 159.5 ft. Brown silty fine sand and gravel,till 0 7 Diameter Slot size_in.from _ft.to ft. Brown fine gravelly sand,siltbound 7 9 Brown fine sand,siltbound,fine round gravel.diy 9 21 Sand/Filter pack:0 Yes No Size of pack material in. Gray silty fine sand and gravel,dry 21 31 Materials placed from.-ft.to_ft. Log 31 32 Surface Seal: Fs Yes O No To what depth? 18 ft. Gray silty fine sand and gravel,dry,or anises 32 36 Material used in seal Bentonite chips40 Did any strata contain unusable water? 0 Yes ! Gray fine silty gravel,saturated 36 No 56 Type ofwater? Depth of strata Gray sandy silt, 50 some gravel 40 Method of sealing strata off Gray clay,moderate 50 59 Gray silty round gravel,loose 59 72 Pump: Manufacturer's Name - Type: Brownish gray silty fine to medium sand and 72 H.P.- Pump intake depth: ft. Designed flow rate: gpm gravel,loose 81 Water Levels: Land-surface elevation above mean sea level 106 ft. Gray fine to medium silty sand and gravel,loose, 81 Stick-up of top of well casing 3 ft.above ground surface moist 100 Static water level 94 ft.below top of well casing Date 6/23/26 Artesian,pressure_lbs.per square inch Date Gray silty sand,moist 100 115 Artesian water is controlled by (cap,valve,etc.) Gray brownish clay,organics 115 143 Gray fine to medium sand,fine to coarse multi- 143 Well rests: colored gravel,loose,heaving,water 160 Was a pumping test performed? K No ❑Yes by whom? Yield_gpm with_ft.drawdown after_lus. Yield_gpm with_ft.drawdown after 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 Bailer test_gpm with—ft.drawdown after_hrs. Air test 40 gpm with stem set at 140 ft.for 1 hrs. Date 6/23/26 Artesian flow_gpm Temperature of water 51 °F Was.a chemical analysis made? ❑Yes E No Start Date 6/22/26 Completed Date 6/23126 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. 7 Driller O Trainee O PE-Print Name Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 344.1 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADD109BK1 Date 6123/26 ECY 050-1-20(Rev 09/18) Ifyou need this document in an alternate format.please call the Mater Resources Program at 360-407-687?. Persons with hearing loss can call 71!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: Kathryn Reese Well Tag#: BQC134 Site Address: 897 SE Dahman Rd, Shelton Depth: 159.5' Date of Test: 6/25/26 Static: 93' Pump Set: 140' TIME GPM LEVEL RECOVERY 1 Min 11= 93.3 TIME LEVEL 2 Min 11 93.3 1 Min 93 3 Min 11 93.3 4 Min 11 93.4 5 Min 18 93.4 6 Min 18 93.6 7 Min 18 93.5 8 Min 18 93.5 9 Min 18 93.5 10 Min 25 93.5 15 Min 25 93.7 20 Min 25 93.7 25 Min 25 93.7 30 Min 25 93.8 35 Min 25 93.8 40 Min 25 93.9 45 Min 25 93.8 50 Min 25 93.8 55 Min 25 93.8 1 Hr 25 93.8 1 Hr 10 Min 25 93.8 Total Gallons Pumped: 1634 Gallons Vanguard Laboratory 2635'?arkmont'Lane-SW,Suite A Qlytripia;'WA 98502 r� ae 360=967 7Q10 CO,L-(FORM.BACTERIA.ANALYSIS FORM`, Date Sample Collected Time Sample County Collected Mason 06/25/2026 3 4 5 o AM Monnr On Year -Is PM Type of Water System(check only one box) .Group.A ❑'Group'B ❑l Other Group'A and Group B Systems—Provide froth Water Facilities Inventory(WFl): ID# System Name:, Kathryn Reese Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:j ) Email: Eve,Phone:( } Send resuitsto,:[(Print full name,address acii zip code ore-mail) adeta@arcadiadrtlltng.com AND jenn@arcadiadriliing;com SAMPLE INFORMATION: Sample collected by(name):Shad Specific,location where,sample collected: Special instrucfons.orcomments: BQG134-897 SE Dahrnan,Rd,Shelton Counts, please Type of.Sample•(select onfyone type ofsainpte f brh types 1 fhroug!5,below)� 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP) Chlorinated:Yes No ttrom'distribuddn system.after unsat.routine) Unsatisfactory routine tab number Chlorine Residual Total__.Free_ 3,Ground Water Rule:Source Sample Unsatisfactory routine collect date: S I i Chlorinated:Yes No- ❑Taggered.(A/P) Chlorine Residual:Total_Free_ ❑Assessment (AIP) 4.Stirface,or GWI Raw Sour6e Water Sample(Enumeration) ❑E.colt ❑Fecal Filtered Yes_No_ 5.©Sample Collected for Information Only: LAB;USE;.ONLY DRINKING WATER-RESULTS` LAB'USE OWL? ❑"UnsatisfactoryTotal Colifonn Presentand •Satisfactory [1 Ecoli present ❑Ecoll absent Bacterial Density Resulfs:.Total Coliform<1.0 /l00mi. E co/t<1.0 /100m1., Fecal Coliform 1100ml. HPC /1 ml. Replacement Sample Required: ❑7NTC ❑'Sample too old ❑ Sample Volume O Damaged Container O DatefTime Received:6/26/2026 Lab Reference Number BIZ. Receipt Temp C': Method Code: SM9223B 922 3 B Date Reported IS DOH Lab Use Only: DON Lab-Sa//mple# 40N rmntF}1t;179 teEecere 6FJ77;.!(ym rrraf puCtii5cmmm aEatla5re?«mal ct7869.525_.0727(ir DnTYCON 711). Tin mid et peeae s&�a aiMla at+nw:d :eag vtdra#ir.7natst.