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HomeMy WebLinkAboutWAT2026-00139 - WAT Application - 9/10/2026 EVAT 2026-.00139 MASON COUNTY COMMUNITY SERVICES Building.Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 •3 Elma: (360)482-5269 ext 400 FAX(360)427-7787 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 on Applicant: f) 1C'W\c- v\ L'.' Date: O G/ Z.0 6 Mailing Address: y 3 D CC1 hp'n Ai'- l,c�tt'f Phone: 3o- l' ( " 73c1 1 Parcel Number: 32o i`1 7 4,OcO'y Type of Water System Reason for Application O Public/Community Water System (2 or more K1 Building permit connections) ❑ Division of land: 6sl Individual water source (one connection), #of Parcels? SPL W Well ❑ 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) O 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. I:EH Forms.Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth 1 2.13 ft. Well capacity Test (attached to application) I 5 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planning 14 15 16 22_ Water use or limitation recorded................................... N/A Yes Well Drilled ............................................................... Date 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 0 o Part 3: Mason County Community Services Evaluation (staff use only) X 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). Reviewer's Signatures: 9/10/2026 Environ. Health: Date CSD Director: Date 2 of 2 DEPARTMENT OF Notice of Intent No.WE62898 WATER WELL REPORT j ECOLOGY Unique Ecology Well ID Tag No.BRB-355 Type of Work: State of Washington Z Construction Site Well Name(if more than one well): ❑ Decommission b Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: Z Domestic El Industrial ❑Municipal Property Owner Name Core Built Construction ❑Dewatering ❑Irrigation El Test Well ❑Other Well Street Address 3370 E Agate Rd Construction Type: Method: Z New well El Alteration El Driven ❑Jetted El Cable Tool City Shelton County Mason El Deepening ❑Other El Dug Z Air- O Mud-Rotary Tax Parcel No.32014-76-00040 Dimensions: Diameter of boring 6 in.,to 128 ft. Was a variance approved for this well? ❑Yes ®No Depth of completed well 126 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread Z ❑ 6 in. +12 126 in. Z I El El I ❑ Location(see instructions on page 2): Z WWM or El EWM ❑ I El _ in. _ - in- Eli ❑ Eli El SE%4-'/4 of the NE¼;Section 14 Township 20N Range 3W ❑ I El in. in. ❑ I El ❑ I El El I ❑ in. in ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345)47.22102 Longitude(Example:-120.12345)-123.01289 Perforations: El Yes Z 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: El Yes Z No El K-Packer b Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size in.from ft.to ft. Lt brown gravel sand clayey silt 0 15 Diameter Slot size in.from ft.to ft. Brown some gravel silt clayey sand 15 19 Gray silty clay 19 53 Sand/Filter pack:El Yes Z No Size of pack material in. Gray gravel sand silt some water 53 55 Materials placed from ft.to ft. Gray silt 55 85 Surface Seal: Z Yes El No To what depth?18 ft. Gray some gravel sand silt some water 85 87 Material used in seal BENTONITE CHIPS Gray silt 87 102 Did any strata contain unusable water? El Yes Z No Type of water? Depth of strata Gray gravel sand silty clay 102 123 Method of sealing strata off Gray gravel sand silt water 123 126 Gray gravel sand clay 126 128 Pump: Manufacturer's Name Type: H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing+1.2 ft.above ground surface Static water level 100 ft.below top of well casing Date 06/28/2026 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? Z 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 gpm with ft.drawdown after_hrs. Air test 15 gpm with stem set at 124 ft.for 1 hrs. Date 06/26/2026 Artesian flow gpm Temperature of water 'F Was a chemical analysis made? ❑Yes Z No Start Date 06/25/2026 Completed Date 06/26/2026 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. Z Driller El Trainee❑PE—Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING Signature 2. y �il Address PO BOX 44427 License No.2432 City,State,Zip TACOMA,WA 98448 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.RICHAW*3210B Date 06/30/2026 ECY 050-1-20(Rev 09/18) 1f you need this document in an alternate formal,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. RICHARDSON WELL DRILLING Aquifer Test Data Well ID# BRB-355 Owner: Core Built Construction Site Address: 3370 E Agate Rd Pumping Well Parcel#: 32014-76-00040 Pump On 07/20/26 12:30 Pump Off 07/20/26 13:30 PM Date Time Date Time Reference Static Level 97.90 Feet Pump Size 1.5 HP 3Ph 3/4 HP 10 GPM Recorded By Time Water Levels Date Clock Elapsed Time Reading In Depth To Drawdown COMMENTS Since Start Gpm Water 7/20/2026 12:30 0:00 2.5 97.90 0.00 12:32 0:02 2.5 99.70 1.80 12:34 0:04 2.5 99.80 1.90 12:36 0:06 7 100.30 2.40 12:38 0:08 7 100.30 2.40 12:40 0:10 7 100.30 2.40 12:45 0:15 7 100.30 2.40 12:50 0:20 12 100.80 2.90 12:55 0:25 12 100.80 2.90 13:00 0:30 18 101.40 3.50 13:05 0:35 20 101.60 3.70 13:10 0:40 20 101.60 3.70 13:15 0:45 20 101.70 3.80 13:20 0:50 20 101.70 3.80 13:25 0:55 20 101.70 3.80 13:30 1:00 20 101.70 3.80 RECOVERY 13:31 1:01 99.90 2.00 13:32 1:02 99.90 2.00 13:33 1:03 99.80 1.90 13:34 1:04 99.70 1.80 13:35 1:05 99.70 1.80 • WATER MANAGEMENT AM LABORATORIES uric- 1515 Both St E,Tacoma,WA 98404 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected icnco1 Mtonfh Day Year Type of Water System(check only one box) ❑Group A ❑Group B Other y Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# s� System Name:�S� �Jt l t)f Gp(15 l'(��LG7j A Contact Person: ,.1 (Scvi r Day Phone:( 53)577...73, Cell Phone:{ ) Email: Eve.Phone:( ) Send results to:(Print name,lull + y . ......._.__.TACQM ..WA_--_9a44fl SAMPLE INFORMATION Sample collected by(name):Specific location where sample collected: Special instructions or comments: 37C' r AteD. Type of mple(select only o type of sample from types 1 through 5 bebw) 1 4outine Distribute Sample(AIP) 2.El 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 I Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total Free_ ❑Assessment (NP) 4. Surface or GWI Raw Source Water Sample(Enumeration) El 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 ❑Ecoli present ❑E.coli absent Bacterial Density Results:Total Colifonn 1100ml. Ecoli 1100ml. Fecal Coliform 1100ml. HPC 11 ml. Replacement Sample Required: ❑TNTC El Sample too old ❑ Sample Volume ❑Damaged Container ❑ to Lab Reference Number Receipt Temp C°: Method Code: Retg.p9Ql /n, Lab Use Only: D Lab-Sample# 086114C 0O1 Farm d 31-191et1ea0ve 06'17)-If you need this pubemtione,en Mtemee famed c$1 800.525.512T(TODrr1Y ca e 711). ��ATE R .:. MANAGEMENT LABORATORIES Nitrate/Nitrite Report of Analysis Date Collected 07-20-2026 System Group Type (circle one) A B otr7er Water System ID Number N/A System Name: Core Built Construction Lab Number/ Sample Number: 089/05619 County. Mason Sample Location At Well - 3370 E Agate Rd. Shelton Source Number(s): (list all sources if blended or composited) Sample Purpose (check appropriate box) Date Received: 07-21-2026 © RC - Routine/Compliance(satisfies monitoring requirements) Date Analyzed 07-21-2026 C - Confirmation(confirmation of chemical result)* Date Reported: 07-27-2026 ❑ I - Investigative (does not satisfy monitoring requirements) Supervisor Initials CL O -Other(specify-does not satisfy monitoring requirements) Sample Composition (check appropriate box) Sample Type: (check one) X� Pre-treatment/Untreated (Raw) ❑ S - Single Source Post-treatment(Finished) B - Blended (list source numbers in "Source Number"field) Unknown or Other C - Composite(list source numbers in "Source Number"field) Sample Collected by Patrick D - Distribution Sample Phone Number 253-537-7332 Send Report & Bill to Richardson Well Drilling Comments PO Box 44427 Tacoma WA 98448 ANALYTICAL RESULTS DOH# ANALYTE DATA RESULTS SDRL TRIGGER MCL UNITS EXCEEDS METHOD/ QUALIFIER MCL? INITIALS 0020 Nitrate as N -- <0.20 0 5 50 10.0 m /L No 300.0/RC NOTES: Confirmation: Include the original lab number, sample number, and collection date of original sample in either comment section. No exisiting value. ANALYTE: The name of an analyte being tested for DATA QUALIFIER: A symbol or letter to denote addtional information about the result. DOH#: Department assigned analyte number. EXCEED MCL: (Maximum Contamination Level): Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-291 WAC Please contact the department's drinking water regional office in your area to determine follow-up actions METHOD/INITIALS: Analytical method used. / Initials of the analyst that performed the analysis mglL: milligrams per liter or parts per million. RESULT: The laboratory reported result. SDRL: (State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the Department of Health TRIGGER: The department's drinking water response level. Systems with contaminants detected at concentrations in excess of this level may be required to take additional samples or monitor more frequently. Please contact the department's drinking water regional office in your area for further information. LAB COMMENTS: