HomeMy WebLinkAboutWAT2025-00001 - WAT Application - 1/7/2025 WAT �OaS -0®001
MASON COUNTY 415,WN. Street
Shelton,WA 96584
Shelton:360427-9670,ExL 400
Public Health & Human Services 116far:360-275407,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 awompany this application.
Part 1: Applicant! Parcel Identification 1
Applicant IMol 1 L L41dJ Date:
Name on Appli � n � nGa,'1Dn-l1I��
Mailing Address:
I F .Lharrl To111ua=Phone:
Parcel Number: i-n le'7!0-nnn lr)
Reason for Application
Type of Water System
Building permit BLDRJ"6 2"'ti 0001
ElPublic/Community Water System(2 or more ❑ Division of land:
connections)
Individual aterWe source(one connection),
#of Parcels?_ SPI.
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ other(explain) ❑ Replacement or Remodel(please indicate name
of water system below if applicable-no
i Byou have more than one residence connected si nature required)
i to this well, check the Publid g
Community Water
i System box.
3
t
Part 2: Water Connection Information
1 Complete the section appropriate for the type of water connection being evaluated:
I
Public Water System
f
i Name of Water System:
Water Facility Inventory(WFI)Number:
(wrtte"none"for two-party)
1
re
i,
1 ❑ Ire the manager of this wonneeetion(s)in use.This system
will be the been appconnection.oved for 5eN1ces. e
i are presently
❑ 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
3 this change:
This water system is able and willing to provide water to this(these)con
necdon(s)without exceeding e
I limits of the water system or any limits set by state and local regulation.
{ Phone
? Print Name of Water System Manager
Date
Signature of Water System Manager
This form may be scanned and available for public view at www masoncountvwa 9 Page t oft
1:rEn Fom onnkina Warr
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to applicetion).
Individual Water Well
application). Depth ft.
�..Water well report(attached to app P _
7 t / d
Well capacity Test(attached to application) Pm P
The well driller often performs well capacity tests at a 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 an
tl recovery data,must be performed
by a licensed contractor.
Satisfactory bacteriological test within last year(attach to application).
Individual SpringlSurface Water
{ ❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide al least 800 gallons per day;and/or
o provides water at a rate o gallons per minute based on the following observations.
Date
Author of Statement
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
rRIcommended
tisfactory Determination: ua of the distribution system,guarantee an adequate supply of
his delemiinalion does not address adequacy applicable WDGE water resource regulations.
ter indefinitely in the future,or guarantee compliance with all
approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.Da0-Datermination of
equacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
.70A RCWnsatisfactory Determination:
plicant's water supply does not appear adequate to meet the needs of its intentletl use for Ne followingason(s).
Reviewer's Signatures: ` �(
f�-ty`o_AM r
Enron. Health: C4-M Date
This form may be scanned and available for public view at www masoncountywa.00, ofz
DEPARTMENT 04 Ned.Of Intent No.IPE58147
WATER WELL REPORT ECOLOGY UnigmF N,,Well Tag No V^HnN
Type of wan: 5xah al wasMngaon Site Well Name(if mere than'one well)
® Cmwoemn Water Right Penlnll/Cen15este Np.
❑ paommisnim O Dneiulinoilhdm Not M.
Pmpned Uw ®Demmue ❑lnduaTil ❑65noipn PropestY Owner Nanlm
R
0Dewasenn8 OInist- ❑Tea Well ❑Onw Well Stseet Address rrtls7 Rd
City^_ Cowry a
A we. 5pn Type: ❑�� ❑bppd ❑C1Ne Tool n9i
New wail ❑Al. O DU ®Air ❑M-das ry Tax Prcel No.71
❑Declonin6 ❑OILer
Dimembu: Diononpfbev6¢
m.,m—fl Was evarianm approved for this well? OYa ®No
Dron of mmdmdwan 9593----fl' If Ya,whet wu tls variance fort
Comttunbn De eaa: Well
Ceens tier Dlveov F. T. TTielme+s Bad PVCW 1 TThxd ®WWM M❑EWM
® 1 ❑ q in. u m" __n. ® I ❑ ❑ Igmdon(sm imtrmtion an page 2).
❑ ❑ in _ _ _b, ❑ 1 ❑ ❑ I ❑ tom&V,.Y.efftSm('Al Semion]$ rawmniP Z2N Range llY
❑ 1 ❑ _b. _ — —b 1,33 1 ❑ ❑ 1 ❑ Ladnde(ExamPle:4712345)
❑ 1 ❑ —m. _ _ _in. ❑ ❑ I ❑ L0ngimde(EBwnPle'-120.12345) n22 3
Padsraeem: ❑Y. ®No Type erperfokmr usN Drlller°a lag/Commecnon or pecomnlmfon Preeedere
Ne.oFpkfonhms— Sim of pednnnnm—b.by—b. Fwmaem'.Deeenbe by ever.cevrrhr.ske afe,menilnd comma.udthekindnd
Pdproed Gam_ft.m_ft.helmv vmMnurDu now<ofine mnmom ncblryerpeemkd,wilh o Imo me enay for each cbuae of
®K-Pancm �' 13pn 2.1 rt i^!°nnahw. Uhadditim.lrNifnenuary-
serew: a ye, ❑No material From To
Mnvfaemm s Name Mode N Lt brown a. ravel sand eitt 0 5
Type 9 B 32
Ilse 9T2e St,size 22_b.arms MILL it is Lt 9nYlsh brown 91edal till
oven _ Sletnev—mfisn —fl.m—fl. Lt gray cobbles gravel billy tlaYBY sand 32 53
vwmin—ie. On revel cleYeY silly sand 53 71
BandMlkr Pecs:D Yn IS
Bier ofpaek Y9 77 BD
Manmils pbced fia0—ft.ro—ft. Lt brown sandy clay 80 1W
S.,sN BeY: ®Ym ❑No T.w tdepO?3g ft. Brown sand silt 106 142
bnmin neee m roil Brown and soma gravel 142 171
Didmymaamene mamma w.n? OYn ON. Lt brownish gray dense and 111 188
Typeofwner? Diieefnau Lt brown silt with flue send ISO 212
M<NadofxanngmvseR Brown silty sand serrN anatl 9T/at M
212 310
Pa.p: Man snnmer'a Name rrpa, Lt 9nY antl Lt brlsvm NM 310 359
HP.— PwpP nuke deptle:—fl. DrnOad flewtW:—BPm Lt nYand Ll brown attt vAl �
fl. Lt gray and Lt brown Sig water 350
Wahr Lereb: Lud'mrfan±L2it above menwnd�. 959 382
Snick-up pfwp ofxell msine'�3b_°b°v°gkmd aurfra Lt yrowmish gray gravel sand tlayry attt
$1We weer levelD3 fl.below lap of well wio6 Aoab2BYlo24
Anmin prnnn—e o-mld d by
aquah mch Date
Annie w.m is wn leW,vnve,me.)
Well Tnb:
WnapumPna sag Rd°rmed? BNe ❑Ym G by whwn?
Yiod—ame whS—ft.dnw7pwn My_—See
YieN —cote wdn—fl.drewdosro aRo—bra.
Yield_�IP^e`rb—fl.dnwdovm afln__bra.
RaeowaY doe Dme-xem whm pump is ovoea oH-wvv oval mnwd fiam watt
mprowon leveD W.Livel
Time Won Level Timm. Wee,Level
T®e
Doe ofPmping
Rkln Sea_Bpe'w'te—fl'mµd0q° —bn� Daro 1MMM4
Air nee U BPm wish teem on at 959 fl.fml M.
niin0.—Sivi Completed Dan
An s^"a°m026
Tantvnnm of weer_°F Wuaehm�id mnYnemde? OYn ®Np $tea Wtea 4n04 —
suoucred Sadler accept resPomlbtbry for comWction oftbis well,Sad in mmpinme wind all Wuhington well
WELL CONSTRUCTION CERTIFICATION: 1 co
consbe,der SWdards,Materials used and the infomntinn rePened above ry me ne my best knowledge alit belief
®di11n❑Tnaulm❑PE-PDetNann Mods Wiex Dnllia Com RICIWRDSON WELL DRILLING
Adders PO BO '44427
ef� Ci Snn Zi TACOMA WA 9874E
Limnse No.2432 Contncnr's
IF TRAINEE:S 'S Licaee No. Re iarntion No.RICNAW'32100 Dar 10/31=4
S Si m
ECY OShI-]A(Rev 09/I8) UYm xed+hn dsmimenl in ten alnmaMJormat Pease m/l de Waln Rexourms Program a+360-101-
__..aa-�r..t....vn mll)ll fiv WnaMwnm Rrinv.Grv+ro Peev.ne wid nawerh AbnMbry cote mll A>JAN.didl
RICHARDSON WELL DRILLING
Aquifer Test Data
Well ID# BOP-040
Owner: Matthew Randle
Site Address 38mEERca Pumping Well Parcel#: 1221876�
Pump ON 11/12/24 4:0
5
Pump On 11/12/24 12:05 Date
Dat
Reference Static Level
308.00 Feet Pump Size lspik30-8_�_
Recorded By
Time Water Levels COMMENTS
Date Clock Elapsed Time Reading In Water
a e o D own
Since St G m
1 ill 12:05 0:00 4 308.00 0.00
PATRICK 12:07 0:02 4 309.10 1.10
12:09 0:04 4 309.10 1.10
12:11 0:08 4 309.10 1.10
12:13 0:08 4 309.10 1.10
12:15 010 4 309.10 1.10
12:20 0.15 7.5 310.70 2.70
12:25 0:20 1 . 311.90 3.80
12:30 025 20 318.00 8.00
12:35 0.30 20 318.10 8.10
1240 0:35 20 316.10 8.10
1245 0:40 20 316.10 8.10
12:50 0:45 20 316.30 8.30
14:55 050 20 316.30 8.30
1S:00 066 20 316.50 8.50
13:05 1:00 20 316.30 8.30
13:15 1.10 20 316.30 8.30
13:25 V2p 20 318.30 8.30
13:35 1 316.30 30 20 8.30
13:45 140 120 316.30 8.30
13:55 1:50 20 316.30 8.30
14:05 2:00 20 316.30 8.30
14:06 2:01 312.00 4.00
RECOVERY 14.07 2:02 311.10 3.10
14:08 2:03 310.30 2.30
14:09 2:04 309.90 1.90
14:10 2:05 309.60 1.60
• `DATER
a MANAGEMENT
AM LABORATORIES I-c.
tat6 a011r M E,Teeeme,WA BMW
COLIFORM BACTERIA ANALYSIS FORM
Dew Senile Caedetl Tane Sample County
,�[� Colbcteed[ ,,/) /
saxa, oar rw
Type of Wabr System(dleck oiy one Eoa)
❑Group A ❑Group B iqDNi
Group Aerd GmWB _pantile fmm Wabr Fad1ilieSlnwnbry(WFI):
IDM -
Syslem Nine:
Gonad Pelson:
Day phone:( ) Cell Phone:( )
Eras:
Swtliwlbb:(PhA hlll name.atltlres����
' SAMPLE INFORMATION
Sanple wftc dby(narne)'.
Spedfic lOaSon wbem sample colkMM: Specialinonablune or o7nmenb'.
cL+ Weu 351
Type Of slapN(salad only we of No*hone Mae 1 No*50Now1 '
1.❑Raudne DlstribuUon SampN(ARP) 2.❑ Rapaal SampN(AIP)
(nme&et,mm systemsear and mAne)
Glodnaled:Yes_No_ Dnsaustafty mmine lab number
ChWm Residual:Toil_Foe_ __ _____
3.Ground Watur Rule Souse Sample Upset wm mike colleddeb'
ICJ _—J_J--
Gbnnabd:Yee_No_
❑Tdgge*(AIP) CNonne ROSA*.Tdd_FWe__
❑Aml wneat (AIP)
d. Sonora on GM Raw Source WAIN Swlple(Enomabbon) I e
❑E.cap ❑Fecal rwa a
5.❑Santa Caliwbtl brkdannaaae Oe(.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umaaafacbry TaW Cakb0 Preaenl iM
❑Ecap pmseot ❑Ecok abxm
p¢Nrial Gamily Reaub:TOW Cokbm ,J7GGml. E.mp__J7GDN.
Fecal Colilotm_ Moral. NPC It cal.
Repl¢emenl SamPN Rayulmd: ❑TWG ❑Sampbloaad
❑ Sa.*Volume ❑Damagatl CaMenar
r C ` � Iap Pebrara Wanbw�
Pscapl Twep C'.
Dame mm0 H l.aau�alow'
DOH SwiWp
— . _i/
.WATER
MANAGEMENT
LABORATORIES iNc. 1515 both St.E
,NEWT-...WA 994N
(253)531-3121
NitratefNitrite
)ate Collected; 11-12-2024 Report of Analysis
System Group Type (circle one) A g Hater System ID Number: NA Cher
ab Number/Sample Number: 089/09510 System Name: Matthew Randle
iample Location: At Well• County; Mason
381 E Richardson Rd, Belfair Source Number(s): (list all sources if blended or composited)
iamole Purpose: (check appropriate box) Date Received. 11-13-2024
® RC-Routine/Compliance(satisfies monitoring requirements) DateA alyzed: 11-13.2024
❑ C-Confirmation(confirmation of chemical result
❑ 1-Investigative(does not satisfy monitoring requirements) Date Reported: 11-20-2024
Supervisor Initials:
❑ O-Other(specify-does not satisfy monitoring requirements)
iample Composition: (check appropriate box)
❑ S-Single Source Sample Type; (check one) ® Pre-treatment/Untreated(Raw)
❑ B- Blended (list Source numbers In"Source Number"field) ❑ Post-treatment(Finished)
❑ C-Composite(list source numbers in"Source Number'fieldCollected
❑ Unknown or Other
❑ D-Distribution Sample ) Sample um a r:2 3- Patrick
;end Report 8 Bill to: Richardson Well Drilling Phone Number:253-537-7332
PO Box 44427 Comments:
Tacoma WA 98448
JOH# ANALYTICAL RESULTS
ANALYTE DATA RESULTS SDRL TRIGGER MCL UNITS EXCEEDS METHOD/
QUALIFIER
0 E Nitrate as MCL? IN
OTES: 1 moll
0 00.
:onflrmation: Include the original lab number, sample number, and collection date of original sample in either comment section.
No exisiting value.
NALYTE: The name of an analyte being tested for.
ATA QUALIFIER:A symbol or letter to denote addtional information about the result.
OH#: Department assigned analyte number.
KCEED MCL: (Maximum Contamination Level): Marked if the contaminant amount exceeds the MCL untler chapters 246r290
Id24G291 WqC. Please contact the department's drinking water regional office in your area to determine follow-up actions.
ETHODIINITIALS:Analytical method used. /Initials of the analyst that pertormed the analysis.
gIL: milligrams per liter or parts per million.
ESULT: The laboratory reported result
DRL: (State Detection Reporting Limit): The minimum repoable detection of an analyte as established by the Department
Health
?IGGER: The department's drinking water response level. Systems with contaminants detected at concentrations in excess of
gional
is level may be required to take additional samples or monitor more frequently. Please contact the department's drinking water
once in your area to further information.
r
1B COMMENTS: