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HomeMy WebLinkAboutWAT2026-00166 - WAT Application - 8/24/2026 WAT 2026-00-166 MASON COUNTY 415N.6'�'Street Shelton,WA 98584 Shelton: Public Health & Human Services 360-227-44 Ext.400 Belfair:360-275-446767,,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 must accompany this application. Part 1: Applicant/ Parcel Identification 8/24/26 Name of Applicant: Marlon & Elizabeth Ridgeway Date: Mailing Address: PO Box 566, Belfair, WA 98528 Phone: 253-380-9040 Parcel Number: 222141190061 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more fl Building permit BLD2026-00766 connections) ❑ Division of land: IZI Individual water source (one connection), # of Parcels? SPL IN Well ❑ Boundary line adjustment ❑ Spring/surface water El (explain) El 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. ❑ 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 Eli Forms Drinking\Vntcr Revised 05/08/2024 Pn«c 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Cpl Water well report (attached to application). Depth 176 ft. W Well capacity Test (attached to application) 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. ® 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 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. Ll Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). kiA Reviewer's Signatures: 8/24/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE62282 ECOLOGY Unique Ecology Well ID Tag No. BRG690 Type of Work: State of'evashington O Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use; IC Domestic ❑Industrial ❑Municipal Property Owner Name Elizabeth Ridgeway ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 240 E Eagle Vista Dr Construction Type: Method: A]New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Belfair County Mason ❑Deepening ❑Other ❑Dug ❑a Air- ❑Mud-Rotary Tax Parcel No. 22214-11-90061 Dimensions: Diameter of boring 6 in.,to 176 ft. Was a variance approved for this well? ❑Yes ©No Depth of completed well 174 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I ❑ 6 in. 0 170 .25 in. U I ❑ 0 ❑ Location(see instructions on page 2): C WWM or❑EWM ❑ ❑ in. in. ❑ ❑ ❑ ❑ NE '/.-%of the NE '/,;Section 14 Township 22N Range 2W ❑ I ❑ in. _ in. ❑ I ❑ ❑ ❑ ❑ I ❑ in in ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.40154 N Longitude(Example:-120.12345) -122.89040 W Perforations: ❑Yes ❑O No Type of perforator used No of perforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to_ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: Lii Yes ❑No ©K-Packer Depth 168 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5„ Slot size.030 in.from 169 ft.to 174 ft. Brown sandy clay 0 2 Diameter Slot size_in.from ft.to_ft. Brown siltbound sand,gravel 2 11 Brown cla bound sand,gravel 11 36 Sand/Filter pack:❑Yes ❑a No Size of pack material in. Materials placed from_ft.to ft. Brown siltbound sand,small to large gravel 36 71 Brown silty clay,sand,gravel 71 104 Surface Seal: E7 Yes ❑No To what depth? 18 ft. Brown silty sand,gravel 104 133 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes t•"7 No Brown silt coarse sand, ea ravel,wet 133 154 Type of water? Depth of strata Brown coarse sand,small to medium gravel, 154 Method of sealing strata off water 176 Pump: Manufacturer's Name Type: H.P. Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 153 ft, Stick-up of top of well casing 1_5 ft.above ground surface Static water level 124 ft.below top of well casing Date 4/6/26 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? C]No ❑Yes b by whom? Yield _gpm with_ft.drawdown after hrs. 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 25 gpm with stem set at 150 ft.for j, , hrs. Date 4/6/26 Artesian flow gpm Temperature of water 50 'F Was a chemical analysis made? ❑Yes K No Start Date 3/31/26 Completed Date 4/6/26 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. ❑Driller C Train�'a❑PE—Pidf N me James Johnson Drilling Company Arcadia Drilling Inc. Signature ; ��.- Address PO Box 1790 License No. 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.2874 Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Date 4/6/26 ECY 050-1-20(Rev 09/18) Ifyou need this document in an alternate format.please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 VD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 04/28/2026 3 ; c DAM Mpnth Day Yew J]PM Type of Water System(check only one box) ❑Group A ❑Group B t Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Elizabeth Ridgeway Contact Person:Arcadia Drilling, Inc Day Phone:(360 )426-3395 Cet Phone:( ) Email: Eve,Phone:{ ) Send results to:(Print full name,address and zip code or e-mail) arleta@arcadiadrilling.com ANDjenn@arcadiadriiling.com SAMPLE INFORMATION Sample collected by(name):Shad Specific location where sample collected: Special instructions or comments: BRG690-240 E Eagle Vista Dr,Belfair Counts please Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(A/PI 2.❑ Repeat Sample(A!P) Chlorinated:Yes No (from distribution system after unsal.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(AIP) Chlorine Residual:Total_Free_ ❑Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E.coli ❑Fecal Filtered Yes-No S 5.Q Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑E.collabsent Bacterial Density Results:Total Coliform <1-0 I100ml. E.coli <1.0 1100ml. Fecal Coliform 1100ml. HPC 11 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Datelrime Received: 4/29/2026 Lab Reference Number — L� Receipt Temp C': Memo/Code: SM9223B 9223 B Date Reported to DOH Lab Use Only: DOH Lab-Sample# 285-y2 Zs- DOH Fpm 33171@ le11ecpre W171-1f fa roved thm peaficaim in w el—ne fcrrnat.call 8x10.525 0127(TDOfnTY cei 711) Ti,re am P 5 C Q s are s Mabee at wwrr dm wagwldnr&gwse