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HomeMy WebLinkAboutWAT2026-00191 - WAI Health Waiver - 9/4/2026 WAT 2026-0O-191 MASON Shelton. l o . A Stre4 Shelton,WA 98584 Public Health & Human Services Shelton: 360-275-4-I6467.Ext.400 Belfair: X60-275--17.Et-I00 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 Name of Applicant: MORRIS ET UX DANIEL L Date: 9/4/2026 Mailing Address: Phone: 1 .206.271.9384 Parcel Number: 323305158001 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more l Building permit BLD2026-00765 connections) 0 Division of land: ISI Individual water source (one connection), #of Parcels? SPL I 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) ❑ 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 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 l Water well report(attached to application). Depth 619 ft. (not a dwelling) IN Well capacity Test (attached to application) 10 gpm N/A 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. l 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) IPq 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. H 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 9/4/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE37635 ECOLOGY Unique Ecology Well ID Tag No. BMS110 Type of Work: state of Washington Cl Construction Site Well Name(if tnore than one well): LII Decommission izzzj Original installation NOI No. Water Right Permit/Certiftcate No. Proposed Use; ❑r Domestic ❑industrial ❑Municipal Property Owner Name Daniel Morris ❑Denatering U Irrigation ❑Test well ❑Other Well 8lreet Address North Robinson Road Construction Type: Method: Xl New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Lilliwaup County Mason ❑Deepening 0 Other 0 Dug L Air- ❑dlud-Rotary Tax Parcel No. 32330-51-58001 Dimensions. Diameter of boring 6 0,10 619 ft. Was a variance approved for this well? ❑Yes C]No Depthofcompletedtcell619 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread Li I ❑ 6 in. 0 619 .250 in. [ I ❑ ] I C7 Location(see instructions on page 2): ©WWM or Cl EWM ❑ ❑ in. ^ in. O I ❑ ❑ I ❑ NE %-y,of the NW '/;,Section 30 Township 23N Range 3W ❑ I ❑ __in. _ in. ❑ I ❑ ❑ I C7 ❑ I ❑ in. in. ❑ I CJ ❑ I ❑ Latitude(Example:47.12345) 47.459550 Longitude(Example: 120.12345) -123.114238 QPerforations: L7 Yes C No Type of perforator rued m No.of perforations Size ofperforations in.by in. Driller's or Decommission Procedure Perforated from ft.to R.below ground surface Formation:Descnbe by color,character,size ofntaterial and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑Yes 91 No O K-Packer r ] Depth ft. infornution. Use additional sheets if necessary. VS Olanu£actureesNane .. Material From - -To Type Model No. Diameter Slot size-in.front -fI.to ft, Brown silty Sand and gravel cobbles 0 4 o Diameter- Slot size in.from it.to ft. Brown silty sand and gravel,loose 4 231 Gray sit sand and gravel 231 234 SandlFilter pack:O Yes ❑� No Size ofp3ck material in. } Gray silty clay 234 376 Materials placed front-ft.to�,.,_ft. Gray silty day with lenses of gravel 376 569 sr Surface Seal: fl Yes ❑No To what depth? 19 ft. o Gray broken sandstone some gravel,water 569 615 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes 17 No Brown broken basalt,some brown sand,gravel 615 0 Type ofwater? Depth of strata water 619 CMethod of sealing strata off C Pump: hlanufacturee'sNaose Type: } IT.P. Pump intake depth:-ft. Designed flow rate: gpm 4O }Pater Levels: Land-surface elevation above mean sea level 240 et. Stick-up of top ofwell casing 15 ft.above ground surface } Static Crater level 121 ft.below top ofwell casing Date 3-27-2020 Artesian pressure-lbs.per square inch Date L. Artesian water is controlled by (cap,valve,etc.) L. L Well Tests: Was a ptmnping test performed? 9 No ❑Yes t=: > by whom? Yield Spin with—ft.drawdown after firs. ZYield gpm with—ft.drawdown after firs. Yield gpm with.11.drawdown after_firs. VS 5) Recovery data(time—zero when pump is turned off water level measured front well top to water level) Time Water Level Time Water Level Time Water Level C ---- ' C U W — , , Date orptaliping.test Bailer test gpm with ft.drawdown after_hr-. Air test 59 gpm with stein set at 509 ft.for.2__.Ins. Date 32720203-27-2020 Artesian flow Virm Temperature ofwater 49 °F Was a chemical analysis niade7 Cl Yes E]No Start Date 3-20-2020 Completed Date 3-27-2020 c3 o�i WELL CONSTRUCTION CER'T'IFICATION: 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 nil F— O Driller©Trainee©PE—Print Namneoshua Koepp Drilling Company Arcadia Drilling Inc. Si nature ' it 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.ARGADD1098K1 Date 3-30-2020 ECY 050-1-20(Rev 09/18) Ifyou need this docrnneut in ail allerrnale format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for lVashinglorr Relay See-rice. Persons with a speech disability can call 877-833-634). Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Daniel Moms Well Tag #: BMS110 Phone: 206-271-9384 Depth: 619' Well Site Address: 300 N Lilliwood Ln, Lilliwaup Pump Set: 240' Date of Test: 5/5/2020 Static: 97' TIME GPM LEVEL RECOVERY 1 Min 10 102.6 TIME LEVEL 2 Min 10 106.8 1 Min 117 3 Min 10 109.4 2 Min 115.8 4 Min 10 110.9 3 Min 110.8 5 Min 10 111.9 4 Min 109 6 Min 10 =112.8 5 Min 107.7 7 Min 10 113.2 6 Min 105.8 8 Min 10 113.8 7 Min 105 9 Min 10 114.1 8 Min 104.5 10 Min 10 114.5 9 Min 104 15 Min 10 115.9 10 Min 103.6 20 Min 10 116.8 25 Min 10 117.4 30 Min 10 117.9 35 Min 10 118.2 40 Min 10 118.8 45 Min 30 119.1 50 Min 30 123.9 55 Min 30 126 11-r 30 127 Vanguard Laboratory 2635 Parkmont Lane SW. Suite A Olympia WA 98502 rarn�-keg 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected V '✓�0 !/ V ❑PM Ns O J Mond1 Day Year Type of Water System(check only one box) Group A El Group B O Other Group and Group B Sy terns—Provide from facilities Inventory(WFI): D# System Name:/n"J�t U Contact Person: 0 Day Phone:(2o ) ( 3 Cell Phone:( ) Email: t' ( t.Lo Eve.Phone:( ) Send results to:(P nt full name, ress and zip code or e-mail) 2us57 9811 SAMPLE INFORMATION Sample collected by(name): - /10f Specific location where same(Ia gqollected: V Special instructions or comments: vo t L,iw)LOA CN Type of Sample(select only one type of sample from types I through 5 below) 1. Routine Distribution Sample(AlP) 2.❑ 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 / / Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total_Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E.coli ❑Fecal Filtered Yes_No 5.❑Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory O E.colipresent O E.coli absent Bacterial Density Results:Total Coliform /100ml. E.coli /100ml. Fecal Coliform /100ml. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date i Receiv : La'/2b e/r nce N rnber _ L' � �, V ro V Receip TempC : Method Code: SM9223B Date Reported to DOH 8/31/2026 Lab Use Only: DOH Lab-Sample# 285- DOH F—9131-319(eMectruea and7)- pu6lia thi ar--ii,,ffile a1 waw.0ah.waf govlankingwzle?5 0127(TDDnTY ca9 7111