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Home My WebLink AboutWAT2025-00027 - WAT Application - 3/12/2025 r WAT MASON COUNTY RECgLyKPs; Public Health & Human Services a i 90-4P-9670,Ea.4 0 sa�t� Application for Determination of Water Adequ1a W'AlderStreet 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: Applicantl Parcel Identification /3 /1- /�� M N Name on Applicant: 1KS ry et`I Date: 1 Mailing Address: A E 1(&MV- Phone: 251, .301 Parcel Number: 67V-y5 �dty Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ❑ Building permit c actions) ❑ Division of land: Individual water source(one connection), #of Parcels SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name ff 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) ❑ 1 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 wwvy.masoncountvwa.9ov J.TH Forms\Drinking W.Wr Revised 05MM024 Page 1 or] it Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth sit Well capacity Test(attached to application)�iL9pm 7 —I D I/ opd. 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 ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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) IfSatisfactory 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). C�jy/Reviewer's Signatures: 17i� Environ. Health Date This form may be scanned and available for public view at www.masoncountvwa.aov Page 2 of2 WATER WELL REPORT IEFARTMENTOF Naieeofhnem No. WE45504 'ECOLOGY uniq.arxaoO,Weil MTvdN. DMMiI3 TTpnN W.k: Slate of WazRNglon a C.awaimn Site Well Neme(ifmaethanon aril). ❑ Rroomiuiw C armail mWhtien NOl No. Water Right PalniUCMif ale No. pursed Um: MCare". ❑IMmid O properly Dwner Neme Mika*AM ❑I orai:g ❑In;mtimn ❑Tevwd ❑orb Well Somet Address 10 E Kayak Cant Csovcoon Type: RMM1ad: MNewwee 0alkeretime ❑Wive, ❑fend ❑Cad.Tml City Shekan County M n ❑Deepening ❑often ❑0, all Ak- ❑MusRauy Tm Pnrtel No. 22020-23-93001 DMemiom: Mime-orl-;na6 u.m 218 4 Wmavarimose,,novedror tiawell7 ❑Ym ONe Depain ofcoaplemdwA 218 L Cammu.no.Da.r: wallIfyes,whet wss Ne variance rt ance fo Ca;eg L—Dumemr peace To TbicW® Seal WCoteKG Iluvl l] 1 ❑ a in 0 214 0.26 w. 0 1 ❑ ID 1 ❑ I tion(sttimtrvctiamonptiF2): OWWMIX❑EWM ❑ 1 ❑ _ _ _in' ❑ 1 ❑ ❑ ❑ SW %XOflk NW %:Sarin, 20 Towmhlp 20N Rrye 2N/ ❑ 1 ❑ h ❑ 1 ❑ ❑ I ❑ timde(Emmpka.@NS)4T 207148 ❑ ❑ _ — _r ❑ 1 ❑ ❑ 1 ❑ le Longilude(Eaample:-120.12M5) 122.987544 pert!m: ❑Ym Mea Type mfpafire«used Fwowion:Dmcri or,c r DerommiMioa Proeeden No ofperraeem_ Sunofper _ o by_m Drilka'r Lop/Construction o size ofinewialaM emwlue,mdlFe 4;otled p.fm:.ead fi..—it aMlow®ouM aura. ecofdv ream io each layce pcacpale4 wits lean oA uury fmr each chaop of &—as: WY. ❑No OK-Pack. d pph212 R. ;oWomimo Ueeconeivmlehe.aifmce, Mmw-e-Neae AAMM fMrlo Works Material Fran To Type Were WraDOad MWd No. Brayxl& 98M8 laVBl 9 32 race- 5_ swsim0la in.fiom 21] it. -15 q INeme-_ sl.rim_ve Ream _n.m_a Gray silt 32 34 MuNcdored yN,bran MaAD send sgt 34 48 et Maccaaracefinee fLw Svedpsk®m:ial_in Gre sll 46 82 M.-;.a placed gem_tm_R. Grey affty aaub8 grawl 62 72 spde.Sral: my. ON. T..WMNh119 a toneW sift 72 73 Mded.l red msml Bemm�lte GYIx &onn sit eaal8 ravel 73 w rdmyme.cmuin:mumblew✓r ❑Y. ON. G al 09 1W Tyleofw.? Dunbar.. Mount ofwlima me o9 &own init,day 10o 10t Green piny G 104 116 p.ap: Mawfiepuer'a Nm. TM Blacksiltycley 116 119 NP._ Pon root dWh:_It Declined Row m:_Nm Gravy silly sand&grainal 119 132 Water Le,ale: lw R. Gary sity,sand,Wet 132 169 So.k.upef"of-11—ace, 1 Aehorc pwdevace Gray medium sped,salt Quawl,and in 175 scom,a-level 1is R.Mmw wp ofwdtmmea torte 10f18/21 Black reve,me ldium bla Ben ck d.loo wMIX, 175 aaeaanpnaare, ba w,ecom a,e, Due s, 17g Mnim wae ne controlledby (cap,vdve.eR) Black fine sandy rml,sit bound,f M,mallet 176 191 well Tests: Grayalty,day city 191 lw Wmaproniagnvperfcarma? lNo OYm O Im.Mm4 Yiew_'no waa R.d.woo,mocr_Ma. Black fine t0 medium heavi aehe iW 199 Yiew_We,with e.d.wmw.aaer—h.. &ay M ..no lans.Ing 199 211 YmM_gpmw;m_R.dmwdowo efi._hn. Gary medlum sand.heavF .W IWT 211 218 Raoruy des(time-mewRen pwmp;r,solo,-wen level memuM five wdl wpmwdukveD Tim Wa-Level Time W.-I<vel Ti— WeMlevcl Ak dpumpioa tev adkr arr.v3_mon a i.e em_a Rm M2w awaotr ai hn. Den 10/1821 Armeimaow_Spm T<mp.Wueeafwaer 50 •F wmaaemid wlyakmtlel ❑Ym oNo glul0.m 1d15121 Complded Date 10f18121 WELL CONFIRUMON CERTWICATION: 1 Cainlon led ea M wept ravpomibility for connotation ordds well and Rs compliance whh an Wasting-,will Consuanlon ste defds.Mderfida uard and do,Information reported atave art true to my bed knmdcdge and M:Idf E Driller Trainee❑PE-print N eJmh K,el1, Cnift Conaparry Arcadia Drilling) Si Curt Addreen PD Bo,1790 LicenceNot 2874 City,Sued,Zip Shelton WA 98581 IF TRADIEE 5 Lie.—No. Contrecke's 3po "S',untatre Rogistration No MCADDI0981<1 Ode IMIN1 ECY1 1-20(Rev09/18) lfymu e.eddRia document m an turmi./ornmr,➢Ivam mR the Water Remmpxx Pmgmmax36"07-M72. Penomw/fh headeg lou Can mil 111/or Waxhmgmn Rday Servtre. Permnr wuhaxpeech dim6111(y Can ml181]d33b341. Arcadia Drilling Inc. P.O.Box 1790 Shelton, WA.98584 Customer: Mike Kivley Well Tag#: BMS083 Site Address: 10 E Kayak Ct,Shelton Depth: 218' Date of Test: 215125 Static: 116' PumpSet: 200' TIME GPM LEVEL RECOVERY 1 Min 123.5 13 TIME LEVEL 2 Min 125.2 13 1 Min 120.6 3 Min 126.3 13 2 Min 119 4 Min 126.9 13 3 Min 117.8 5 Min 127 13 4 Min 117.3 6 Min 127 13 5 Min 117 7 Min 127 13 6 Min 116.7 8 Min 127 13 7 Min 116.6 9 Min 127 13 8 Min 116.6 10 Min 127 13 9 Min 116.6 15 Min 127.1 13 10 Min 116.6 20 Min 127.1 13 25 Min 1 127.2 13 30 Min 127.3 13 35 Min 127.3 13 40 Min 127.4 13 45 Min 127.4 1 13 50 Min 127.4 13 55 Min 127.6 13 1 Hr 127.6 13 F a BeYSngla QfeW iMSeapt' 2 5Iz5 L D° YY1q on 4 T�ynarwntr9/ero(a.euyurEaq - . ❑OWA I]Ouge Gh Aa Ca BSyd.-Ri tun WMK t.A.bmby a arc — CugctPomn . Dayfl IkIPYvst ) . 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