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HomeMy WebLinkAboutWAT2026-00095 - WAT Application - 8/24/2026 WAT 2026-0Q095 • MASON COUNTY 415 N.6a'Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human er ices 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 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/ Parr ell{!denttiification Name on Applicant: Date: f// f Mailing Address: ft7 2QX SL ( 661,0421V4 /vflPhone: �__ _ Parcel Number: ,o Type of Water System Reason for Application / 0 Public/Community Water System (2 or more ® Building permit connections) ❑ Division of land: Ea0 Individual ater source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water lain❑ Other ex ❑ Other(explain) (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 J:\EH Forrns\Drinking Water Revised 05/08/2024 Page 1 of2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well li Water well report(attached to application). Depth 379 ft. 0 Well capacity Test (attached to application) 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 p . Part 3: Mason County Community Services Evaluation (staff use only) J 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). }ry5L Reviewer's Signatures: 8/24/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of2 WATER WELL REPORT DEPARTMENT Of NotieeofltitentNo. WE62877 ECOLOGY Unique Ecology Well ID Tag No. BRL 634 Type or 11'ork: State of Washington O Construction Site Well Nance(if more than one well): ❑ Decommission b Original installation NOT No. Water Right Permit/Certificate No. Proposed Use: d Domestic ❑Industrial ❑Municipal Property Owner Name Reid Garcia ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address E Grapeview Loop Rd-LOT:3 OF SP#562 Construction Type: Method: x New well ❑Alteration ❑Driven O Jetted O Cable Tool City Grapeyiew County Mason ❑Deepening ❑Other ❑Dug [I]Air- ❑Mud-Rotary Tax Parcel No. 12108-22-90100 Dimensions: Diameter ofboring 6 in,to 380 ft Was a variance approved for this well? ❑Yes r❑No Depth of completed well 379 ft, If yes,what as the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread R I O 6 in. +5 347 ,25 in. RI I O ❑ 1 O Location(ssoc instructions on page 2): 1 WWM or❑EWM ❑ I ❑ in, in. ❑ I ❑ ❑ I © NW r/4-t/4 of the NW 1/4;Section 08 Township 21 N Range 01 ❑ ❑ in. in. ❑ I ❑ ❑ ❑ ❑ ❑ in. — in. ❑ I ❑ ❑ i ❑ Latitude(Example:47.12345) 47.32957 Longitude(Example:-120.12345) -122.84164 Perforations: O Yes C No Type of perforator used No.of perforations Size of perforations in.by in. Di'lller's Log/Construction or Deeolmntlssion 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: C Yes ❑No ©K-Packer Depth 373 R. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material Front To Type Stainless Steel Model No. Diameter 5 in. Slot size .018 in.from 374 fl,to 379 ft. Top soil 0 1 Diameter in Stot size in.from ft.to_ti. Clay,silt, some gravel,brown/soft 1 4 Sand/Filter pack:ElYes i No Size of pack material is Clay,brown/hard 4 38 Materials placed from ft.to ft Clay,Some gravel, gray/soft 38 52 Clay, gray/hard 52 60 Surface Seal: N Yes U No To what depth? 18 IL Material used in seal Bentonite Granular Sand ravel silt,few cobbles brown/soft 60 75 Did any strata contain unusable water? U Yes A No Sa- iiP1 graver,sill,little water,very silt Type of water? Depth ofstrata brown/hard 75 115 Method of sealing strata off Sand,coarse,gravel,silt,very sill,brown/soft wb 115 128 Pump: Manufacturer's Frame NIA Type: Sand,silt,very sitty little water, brown/soft 128 336 H.P. Pump intake depth: ft. Designed flow rate: gpm Sand,more coarse,some small pea gravel Water Levels: Land-surface elevation above mean sea level ft. sill,brown/soft,wb 336 370 Stick-up oftop ofwell casing +5 ft-above ground surface Static water level 43 ft.below top of well casing Date 6/2612026 Sand,silt,gravel,gray/hard,wb 370 380 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? G No ❑Yes cnn> by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with, _,ft.drawdown after hrs. Yield gpm with_A.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 his. Air test 70 gpm with stem set at 373 ft.for 1 hrs. Date 6/2612026 Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes ©No Start Date 6/22/2026 Completed Date 6/26/2026 R'ELL CONSTRUC'T'ION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well constriction standards.Materials used and the information reported above are true to my best knowledge and belief. iJ Driller❑Trainee❑PE—Pr'it Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature p,..�y Address 1162 NW Slate Avenue License No. 2253 City,State,Zip Chehalis,WA 98532 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. MOERKSP072N5 Date 6/29/2026 ECY 050-1-20(Rev 11/18) 1/you need this document in an alternate format,please call the ftrater Resources Program at 360-407-6872. Persons with hearing loss con call 711 for It'ashingfovt Relay Service. Persons with a speech disability cart call 877-833.6341. MOERKE & SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST RIED GARCIA 8/11/2026 WELL SITE ADDRESS: 4141 E GRAPEVIEW LOOP RD, GRAPEVIEW WA, 98524 Pump Make & Model: 3 HI' 25 GPM Pump Set At: 300' Sounder Make & Model: Make & Model: Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 29 30076 49'4" 1 28 30105 64'3" 2 28 30133 71'6" 3 28 30161 74'9" 4 28 30189 76'10" 5 28 30217 78'5" 6 28 30245 79' 7 28 30273 79'6" 8 28 30301 79'9" 9 28 30329 80' 10 28 30357 80'5" 15 28 30497 80'6" 20 28 30637 80'9" 25 28 30777 80'10" 30 30917 8011" 800 GAL TOTALIZATION COMPLETE SIGNATURE: MOERKE AND SONS PUMP AND DR LLING 7UG AUG26 '6t"�iguatii Lff<'b+axlrY ' TT 2635 Pant LanD SW`;Suite A blynt,1aOVA.98S02 v io •S�'t}967-70113 t ro t/PO4 CCI.IFORM BACTERIA ANALYSIS FORM aateftVietottected to County RGemtli !k7 Yex —�+—' -- 'typecPVdabrSy+�9tn{dtodton1y0R9PMUt) ®L= A 13amp0 Clfi GroiPAGnd group f3Sfreteme_FtovidehvreWabrFa6�tnvaldorylVUFt): 5yownName: fib . C)t, Conte t� *' flayP1rnno( 0) CottPhtm ( ) Qnatt: "Phone:( ) J ra t name, .�Pam r 5Mpaco8ected ty ama). &panto iucoU b creder zb smat� q)Lt VV+4►coaaviU.,r p Rc4 t w 'typact&am Pe(aelectcn Oneiypeoisarnp4airpin 9ttir�llph�fJelmsl) f. RouUno Dfatrtt Won 8ampte(Alp) 2. p Roppm1 fdanfpte(A!p) Chtortnotd.Yfm PVo:,.,,� t na�ma�trrta ttauunef Ct16&ORe9ftkTota1.,_Free,_,_ C'�a yron�tatabaumtrar; 3.f3raundWaterRulseaurmf empte " " ""°�"* SLLJ IJnes�taoduyrtaAineoa8actdatea . ..J,... __ Chtotnatad:Y ,_ Nu . Ofte,W00) Chkr6teR�Pdt�! [pta�tze 13 A9sasam mt(AM) 4.fjurfatiaor4Wtfwourr�w®torRamfa(�numaratl�) CELcoil pFeel ,I aY„__ l;. pteCa98 wfa'lnfadonon(n LAS USE ONLY tRIN ING WATER RESULTS LAB USE ONLY Oun+�atteraauwTommkrenJ�m atend • i BeUereatory ' ��co�preseni ®��9a�r�nt '0aototfatC6nstty!'taeulfaToWCuf}farnlM..,_..,.�.JfllQ�nf.� dllmF, Fact CoidwmE jfooA HPG- ff rnt (teptRanrentdat»phafiequGodt O1NTC C(ffaroptnmaot*t l0 Samplov*, 4DemagersCcnlaber C,�„ Re FtTanDf;'r fJ adtkt SM9223B Dataftpa4edtaOW LbUpay. 285j3 3 3Z.- Vanguard x.aboratory 2635 Pprkmont Lane SW,Suite A Olympia WA 98502 360-467 7010 Nitrate/Nitrite Analysis Report to Collected: MWou l S steam Grou e: CGxleansr� A er: Water S stem ID Number, S stem dame: e Lab Number Sam ie Number. 2 8 8 1 3 3 2 Count . Sample Locotion 'aa ,�,r, Source Number(s) fttstaltsqurcesif6lendsd orcompwuedj Samp a Purpose the ckapproprtokebox) bate Received: (MM/pamt) f f RC floutlne/Compiiance(5 tgres rnonUarfng requirements) Date Analyzed: (MMlratW) PJ 1 2 ® C—Confirmation(Cpn„fl'rmat(pn ofcd�e�n(ccrtrosutt)6 Date Reported; (MWD0/YY) Q 1 6.,_m, O I--Investigative(ooesnotsutcs�ymunaorfng requtremenis) CC?MM�Nt'S: Q--tether tS aesnatx manfrorFngm fromerrtcp �. Sample Composition(Check appmprtate bog Sample Type(Check one) Pre-treatment/Untreated(Raw) Single Source C]Post�treatmertt(plrrlshed) UB—Blended(ttstsourc s"enumbarrin"source NumberFeld) pUnknown orOther O C--Composite t'ttstsour�cenumbersln'Souroe Numbers?(tetdJ Sample Collected by;(germ) 1 •oIstribution yarn le Phone Number: I •Send RE ore to: Bill to:{cttentnome) r� li Analytical Results Data WeedsMCL? Me*od/ DON# Contaminant ualmar Results MRL Sr K Td sr MCL units (t{Nf Ysss Initlaip 0020 Nitrate•N 03 0.5 5,0 100 m Hach 10206 ` NOTES *Confirmation:include the original lab number,sample number,and collection date of original sample in either comment section, ..-No trigger value for combined nitrate plus nitrite. Data 4uailfier.A symbol or letter to denote additional information about the result. DOH#i Department assigned contaminant number. Exceeds MCL(Mmdnnurn Contaminant Level);Marked If the contaminant amount exceeds the MCI under chapters 246«290 and 246- 291 WAC. If you have questions about this result please contact the department's drinking water regional office in your area. MEDIOD/INt'fALS;Analytical method used//initials of the analystthat performed the analysis, mg/L milligrams per liter or parts per million. MAL(Method Reporting Limit);The lowest quantifiable concentration of a contaminant SORL(State Detection Reporting Limit);The minimum reportable detection of a contaminant as established by the department 'Trigger.The department's thinking water response level,Systems with contaminants detected at concentrations at or above this level maybe required to take additional samples or monitor more frequently. e LAB COMMENTS Revised December 2021