HomeMy WebLinkAboutWAT2026-00190 - WAT Application - 9/1/2026 WAT 2026-00190 Mego
- COUNTY
415 N.6��Street
J Shelton,WA 98584
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u �lbhl � edli 'ilHuman Services Shelton:360-427-9670,Ext.400
Belfair: 360-275-4467,Ext.400
Application for Determination of VVate!r Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is full 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: �, e � i �s' f , j®ian��r,_ Date:
Mailing Address: ( ' r-> , 3�, �x�a lad/}•qPhOfle:
Parcel Number: � A �� °. �� P`, �
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit
connections) O Division of land:
AIndividual water source (one connection), #of Parcels? SPL_
Well O Boundary line adjustment
❑ Spring/surface water
O Other(explain) O Other (explain)
O 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 forirn may be scanned and available for public view at www.masoncountywa.yov
.I:\EH Fonns\Drinking Water Revised 05/08/2024 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.
TM 9 >400
Well capacity Test (attached to application) �___ gpm— 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
❑ 1NDOE 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)
IX 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). _— _
�y�5lti Reviewer's Signatures: 9/1/2026
Environ. Health: Date
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. WE61149
ECOLOGY Unique Ecology Well ID Tag No, BQC 483
Type of Work: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: ❑� Domestic ❑Industrial ❑Municipal Property Owner Name Marty&Renae Million
❑Dewatering ❑Irrigation ❑Test Well ❑Other
Well Street Address 240 E Sullivan St
Construction Type: Method:
❑D New well ❑Alteration ❑Driven ❑Jetted ❑� Cable Tool City Allyn County Mason
❑Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No, 122205058009
Dimensions: Diameter of boring 6 in.,to 110 ft
Was a variance approved for this well? ❑Yes ❑No
Depth of completed well 105 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 98 1/4 in. FE ❑ 0 ❑ Location(see instructions on page 2): ❑WWM or❑EWM
❑ ❑ in. in. ❑ ❑ ❑ ❑ SW 14.1,of the NE ',;Section 20 Township 22N Range 1W
❑ ❑ in. in. ❑ ❑ ❑ ❑
❑ ❑ in. in. ❑ ❑ ❑ ❑ Latitude(Example:47.12345) 47.385278,-122.828877
Longitude(Example:-120.12345)
Perforations: ❑Yes ❑No Type of perforator used
N
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 ❑No ❑0 K-Packer Depth 92 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type stainless Model No.
Diameter 5 in. Slot size 10 in.from 95 ft to 105 ft Gravel w/topsoil 0 4
Diameter in. Slot size in.from ft.to ft. Brown clay bound sand&gravel 4 20
Grey sand&gravel 20 30
Sand/Filter pack: ❑Yes ❑No Size of pack material in. Beige clay 30 38
Materials placed from ft.to ft.
Light brown clay bound fine sand&gravel 38 60
Surface Seal: s Yes ❑No To what depth? 20 ft. Light brown wet fine sand some clay balls 60 90
Material used in seal bentonite
Fine brown sand wb 90 110
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. 3/4 Pump intake depth:80 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 37 ft.below top of well casing Date
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 20 gpm with 117 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 12/29/25 Completed Date 1/6/26
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
0 Driller❑Trainee PE—PrintName Emily Davis Drilling Company Davis Drilling
Signature Address 340 NE Davis Farm RD
License No. 3142 City,State,Zip Belfair,WA 98528
IF TRAINEE:Sponsor's License No, Contractor's
Sponsor's Signature Registration No,DAVISD1110OA Date JAN 2026
ECY 050-1-20(Rev 08/19)If you need this document in an alternate format,please call the 1Pater Resources Program at 360-407-6872.
Persons with hear'/ng loss can call 711 for Washington Relay Service. Persons with a speech disability can call 87 7-833-6341.
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.
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