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HomeMy WebLinkAboutWAT2026-00171 - WAT Application - 9/1/2026 WAT ô - DO 1 ., . 415 N.6 Street Shelton,WA 98584 SheltoPublic Health & Human Services Belfan:360-275-4467,Ext.400 Public elfau•:360-275-4467,Ext.400 Application for Deter ination 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: I`—I Le Date: ' 2 2jp Mailing Address: Pcrje-X '2A3 I CCyN % hone: k3 3hbI U19 Parcel Number: 22-0 (°I 2Z £�C� J 2-. ki a Co - 6D 1 q ci Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL ,19--Tvell 0 Boundary line adjustment ❑ 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 05/051202-4 Page i of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well © Water well report (attached to application). Depth ft. l Well capacity Test(attached to application) +U 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. 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) Xi 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. ci 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 9/1/2026 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, WE57643 ECOLOGY Unique Ecology Well ID Tag No, BQC 307 Type of\\ork: State of Washington 0 Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOT No. Water Right Permit,Certificate No, Proposed Use: A Domestic ❑Industrial ❑Municipal ❑Dewatering ❑Irrigation ❑Test Well ❑Other Property Owner Name Riley Reynolds Well Street Address Old Farm Rd Construction Type: Method: D New well ❑Alteration ❑Driven ❑Jetted 41 Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No, 220192290012 Dimensions: Diameter of boring 6 in.,to 191 ft Was a variance approved for this well? ❑Yes ❑No Depth of completed well 191 ft If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 0 ❑ 6 in. +1 188 1/4 ill. FE ❑ D ❑ Location(see instructions on page 2): ❑WWM or❑EWM ❑ ❑ in. in. ❑ ❑ ❑ ❑ NW '/4-'/4of the NW '/4;Section 19 Township 20N Range 2W ❑ ❑ in. in. ❑ ❑ ❑ ❑ ❑ ❑ in. in. ❑ ❑ ❑ ❑ Latitude(Example:47.12345) 47.212923,-122.988188 Longitude(Example:-120.12345) Perforations: ❑Yes No Type of perforator used No of perforations Size of perforations in by in. Drillel's Log/Construction or Decommission Procedure 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 laver penetrated,with at least one entry for each change of Screens: ❑D Yes ❑No K-Packer Depth 184 ft information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Model No. Diameter 5 in. Slot size 14 in.from 186 ft to 191 ft Top soil 0 2 Diameter in. Slot size in.from ft.to ft. Brown till 2 40 Sandy blue clay with water 40 160 Sand/Filter pack: ❑Yes No Size of pack material in. Packed blue clay with gravel 160 185 Materials placed from ft.to ft. Grey sand&gravel w/water 185 191 Surface Seal: Yes ❑No To what depth? 20 ft. Material used in seal Bentonite Did any strata contain unusable water? ❑Yes No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name goulds Type: sub H.P. 1 Pump intake depth: 180 ft. Designed flow rate: 1 5 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing ft.above ground surface Static water level 155 ft.below top of well casing Date AUG 2026 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ❑No ❑Yes 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 j5 gpm with 110 ft.drawdown after 1 hrs. Air test gpm with stem set at ft.for hrs. Date Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes ❑No Start Date 7/25/26 Completed Date 8/23/26 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 0 Driller❑Trainee ❑PE—Print Name Mike Davis Drilling Company Davis Drilling Signature Address 340 NE Davis Farm Rd License No, 0797 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No, Contractor's Sponsor's Signature Registration No, DavisDl110OA Date AUG 2026 ECY 050-1-20(Rev 08/19)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. WATER WELL/DEWATERING SYSTEM CONSTRUCTION PROCESS After a well is constructed.modified or decommissioned,a well report must be filed within 30 days to the Department of Ecology.Well reports are filled out by the person who constructed the well. This is typically a Washington State licensed well operator. The following form is used for water wells and dewatering systems only.Below are the instructions for filling out a water well report. After the form has been printed and filled out,it should be mailed to the Department of Ecology Regional Office responsible for the area the well work was conducted. INSTRUCTIONS Type of Work—This form is used for BOTH construction and decommissioning of a well.Please check the appropriate box.For decommissioning—enter the original construction Notice of Intent No. here(if available). Dimensions—Nominal diameter of uncased boring(drill bit size)and total depth drilled.Depth of completed well may be different from total depth drilled. Construction Details—Choose either Casing or Liner.Enter nominal diameter and depth range. Check the type of material and whether it was welded or threaded. A description of mechanically locked liners may be added to the Driller's Log/Construction Procedures section. Perforations—Well casing perforations:read each statement and answer appropriately. Screens—Well screens and screen assembly information. A K-packer is designed to provide a sand tight seal between a well screen assembly and casing. Sand/Filter Pack—Read each statement and answer appropriately. Surface Seal—Read each statement and answer accurately. Water Levels—Casing stick-up means the height,in feet,the well casing rises above ground surface(preferably measured to the hundredth tie. 2.34 ft]).Static water level is the depth,in feet,to the water surface inside the well or boring (preferably measured to the hundredth tie. 6.78 ft]). A static water level implies the measurement is not disturbed by pumping or drilling,or a nearby well that is pumping. Include the date the measurement was taken. Artesian pressure is the gauge reading of a flowing artesian well with the valve closed(shut-in pressure),reported in psi. Well Tests—A pumping test is the process of pumping groundwater out of a well and measuring the water level response through time. This process is the best way to determine the efficiency of the well.Drawdown is the amount the water level is lowered below static level when pumping. A bailer test is a common way to test well efficiency while cable-tool drilling,whereby a tool called a bailer is used to pull up and dump water onto the ground, simulating pumping. An air test is commonly used when drilling an air-rotary well to estimate well production, since an air compressor is always on hand. Notice of Intent No.—The number issued by the Department of Ecology for tracking purposes(e.g.,W123456). Should start with a W, A or D for this form. Unique Ecology Well ID Tag No.—The number issued by the Department of Ecology that is stamped on a metal tag that is attached to the actual well. (e.g.,AAA-000) Site Well Name(if more than one well): If there is more than one well on the site,you may identify each well with a site well name or number and place it in this space. This is different from the Unique Ecology Well ID Tag No. Water Right Permit/Certificate No.—If the well will use more than 5,000 gallons per day or irrigate more than 1/2 acre of land,you must have a water right. This number should be written here. Property Owner Name—The name of the property owner. Well Street Address—The physical address where the well is located. (Note:NOT the mailing address.) City—City where the well is located. County—County where the well is located. Tax Parcel No.—County tax parcel number-enter ROW for right-of-way. Was a variance approved?—A variance request is submitted to a regional well coordinator if the regulations cannot be met. Explain the request here. Location—The quarter-quarter,quarter, section,township and range(TRS)of the well.For example: the SE 1/4-1/4 of the NE 1/4, S 10,T20N,R05—and then check box for West or East of the Willamnette Meridian[WTI'IL�EWM]for range. The web based State Well Report Viewer in map view is one of the best places to determine well location using the TRS system. Latitude/Longitude—Using a GPS or web-based coordinates,enter the latitude and longitude of the well using the WGS84 coordinate system.Please input to the fifth decimal place. Driller's Log/Construction or Decommission Procedure—Describe the geologic materials encountered while boring. Also,decommissioning procedures,additional location notes,or unusual aspects of the project can be written here. Well Construction Certification—Read the statements,enter the Driller and Drilling Company information; sign and date in the blanks provided. A sponsor is the licensed driller that is responsible for a trainee according to 173-162 WAC. ECY 050-1-20(Rev 08/19) If you 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 8 -833-6341. 1 26276 Twelve I Trees Ln NAl ste.C " SPECTRA Labclratorit:s I£itsap Poulsbo,WA i .:.Where r?�;e-ezz a maurrx . 98370 H`^— (36q)779 star COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected r Time Sample County p l z Collected I Nunth Day Ysar W C]PM C-�/ 1 Type of Water System(check only one box) ❑Group A ❑Group 8 Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFI): ID# . System Name: Contact Person: 3( )- Day Phone: I Cell Phone — I Email: (�vt5 Y r�� ? Phone Send results to:(Print Nil nerne.address and zip code or email above for electronic copy of resuttej { .._.._ _ SAMPLE INFORMATION Sample collected by(name): ``�` �) I1 Specific location where sample collected; Special instructions or comments: Type of Sample(check only one box) 1.El Routine Distribution Sample(NP) 2.❑Repeat.�......__..__,p.._( �peatSampte(A1P) Chlorinated:Yes ❑ No 0 (from dism'btrton system alter unset.routine) Unsatisfactory routine lab number: Chlorine Residual:Total__Free__ 3.Ground Water Rule Source Sample ——— ————— S I Unsatisfactory routine collect date: r € Chlorinated:Yes__. ( ❑Triggered (Am) ) Chlorine Residual:Total_.Free,..__,. ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) f _ ❑ E.coil ❑Fecal Pineed Yee—No-- �____________ 5. Sample Collected for Info matlon Only; LAB USE ONLY DRINKING WATER RESULTS . -LAS USE-ONLY ©Unsatisfactory Total Coliform Present and jSatiSfaCtOrY ❑E.coll present ❑E.colabsent Bacterial Density Results:Total Coliform mpnllDOmi.E.co6 mpn/1ODml. FecalColifotm_ , �_._cfullOOml. HPC cfu/tmt. 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