HomeMy WebLinkAboutWAT2025-00100 - WAT Application - 6/17/2025 Z
MASON COUNTY it
COMMUNITY DEVELOPMENT
- O0I 00
Permit Assistance Center.Building,Planning
415 N 61'Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •:• 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: Richard Atkinson Date:
Mailing Address: 300 NE Haven Lake Dr, Tahuya-jPhone: 253-297-1342
Parcel Number. 22330-50-00307
Type of Water System Reason for Application
CI Public/Community Water System (2 or more 0 Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
0 Other(explain) ❑ Other(explain)
0 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 Rocking R Water System ,
Water Facility Inventory (WFI) Number-A' n� ) f 0 S G
(write"none"for two-party)
0 1 am the manager of this water system. The water system has been approved for 6 services.
There are presently 1/ connection(s) in use. This will be the 2 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 Iimi $(zt by state and local regulation.
Signature of Water System Manager Ri,r- No,t)r-- Date_ 6 - 7 _ -.C-
This form may be scanned and available for public view at www.co.mason.wa.us.
JAE.H Forms\Drinking Water Revised 112:/2018
Individual Water Well
❑ Water well report(attached to application). Depth 308 ft.
El Well capacity Test (attached to application) 30 gpm 43,200 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.
CI Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA httpl/qis.co.mason.wa.us/planninc 141_1 15n 160 221-1
Water use or limitation recorded N/A El Yes 0
Well Drilled Date 10/17/1995
Individual Spring/Surface Water
El WDOE permit(attach to application)
El 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)
►: 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:
Environ. Health: pNi Date
°t
CSD Director: Date
twaOa5-(2b53s-
seen era fa. W 074820
F "'°' WATER WELL REPORT UNtOLIE WELL 1.D.e ABV 927
Second Copy—CrneraCopy STATE OF WASHINGTON
Third Copy—Drllfere CdPlr Water Right Permit No._
(1) OWNER: Nome Ralph Herth Adele. NE 302 Haven Lk
Lk Dr Tahuya WA 98588
' (2) LOCATION OF WELL Court', Mason Coson NW 11e SE 1/1 Sec 30 T 23 N.R 2W W.M.
po sniEETAODRESSOFIIVELL(o<nearaladde») NE 302 Haven Lk Dr Tahuya WA 98588
(3) PROPOSED USE: B Domesec Industrial r Municipal p (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
LI 4rtpfttOn❑ DaWttbetcoax.Teal Well 0 Other 0 Formation Demob'by co .character.airs or malarial and elructure.and show thicanee,or'queers
and lie klyd srd meter'of the malarial In each thetum pane/mod,with al beat one entry k.each
(4) TYPE OF WORK: Owfte(It mre number of eel chino or inbrmetion
ore start oe)
Abandoned ❑ New well IX Method: Dug 7 Bored G MATERIAL FROM TO
Deepened ❑ Cabis GI Drven❑
R.00ncitioned C Rotary 0 Petted] Brown conglomorate 0 4
(5) DIMENSIONS: Dlam.ter of wen 6 _ inches.
11Iled 308 feet Depth of Completed well 308 _- h. Hardpan -- . 4 85 -
(6) CONSTRUCTION DETAILS: Sand 85 130
Casing installed: 6 • Diem.from 0__e to_ 303 ft
Welded itl • Diem.from fl.to h.Liner
Threed installed 0 • Diem.from ft.to rt. Hardpan 130 200
Perforations: Ala p No® Sand & gravel (dry) 200 220
Type of perforator used -_-
SIZE of perkstations - ---In.by - - i,. Hardpan -- ' 220 - 270
perforations from ft to ft.
perforations from " '° ' Cemented sand & gravel with water 270 302
perforation'from ft to ft.
Scena: Yea[I No ❑ Sand & gravel with watts
302 308
Manufacturer's Name Cook r
TYpa - stainless wire wrap Model No. 1
Diem. 5 slot size 50 rrnm 303 kw 308 ft. �,-
Diem. Sat size- from IL to It Ni�O
\V/ 1T
Gravel pecked: Yea ❑ No® sae or gravel ` 7.
G' r�
Dravel placed from ft.b CJ`' ^� z r tv
Surface seal: Yes 03 No 0 To what depth? 18 \ n. ��j��L �,��gP- i- x
NAatsrvl ue.d vh east Betonite �p JrDON\rFNTAL= cr
-
Oldanaunusablewater? Yes❑ No ® hsType of wa / Dth a1 atrte ) , L
Methoda/seal strata elf -- F1 _ Iri ELT N
(7) PUMP: rye,Name CrtIIndf Oa
Type' SLLD• - ---- H.P. 5 -
, (8) WATER LEVELS: wed,shamed 9%26/95 .19. Coll ratted 10/17/95 .19. _
swim mein sea SSabo lever 245 it
bale.top of..en Dab
Artesian pressure _ tutper square nob Der WELL CONSTRUCTOR CERTIFICATION:
Anrslan water.oonaoerd by 1 constructed andlor accept responsibility for Construction of this well, and its
(Cap,revs.Mc) compliance with all Washington well construction standards. Materials used and
(9) WELL TESTS: Diawdown is amount wader level is lowered below static level the irtformaticn repotted above are true to my best knowledge and belief.
Was a pump tat made?Yes ] No❑ If yes,by whom/ Davis_1 NAME
Yield: Davis Drilling
30 pet./min.with 16 ft.drewdown after 1 has Iv1:it9ett MY ORtakoaarcee (TYPE on mean
30 16 - 2 Address Belfair WA 9.8528
30 - 16 - 4
Recoveryturned dela(time taken as zero when pump of)(water level measured from well (Sig Jnj--! L
tu1DR'' License No. 2062
by b water level)
vet Time Water Level rime Water haute t;prttJa,tdr 9
10 min 245trabon
1 min 247.5 No nAVISDI1100A Date Oct. _.1e 95
2 Trim. 245.5' - (USE ADDITIONAL SHEETS IF NECESSARY)
Date of test
Bader test gal/mkt.with ft.clampdown after faa.
Airiest gelumin.with stem set at ft.for tea. Ecology is an Equal Opportunity and Affirmative Action employer. For spa•
g p m Oats clal accommodation needs,contact the Water Resources Program at(206)
*rumen flowTemperature of water Was a chemical arnlya s mode? Yes�] No El407 66d0.The TDD number is(206)407-6006.
cr.,nc,,.ti,tuna,•-I 1l
2221 Ross Way Spectra Laboratories -Tacoma
Tacoma WA ( "�
98421 Spectra# 3`0i / DJo 1
(253)272-4850
COLIFORM BACTERIA ANALYSIS FORM
Date Sam Tune Sample County
± !?c
7 :�m-- the°4
Type of Water System(check only one box)
❑Group A Group 13 ❑Other
Group an p from Water Facilities Inventory(WFI):
Y /�
IO4 j
System Name or Address: 3.5e
0 "'tigvc /� �� , z—
Contact Person: 1L.j 0�n 54�
Pon �9 7 -i3
Email: 1 k_,s'1. , l df 7ec 0w14-.'i Cc4'
Send m n..511ts to:Prvrttul no adore«.ZIP cods.a law
SAMPLE INFORMATION
Sample collected by(name):Ae-k- A lh see
Specific location where sample coiected:: Special instructions or canments:
9Cif5/de ` -j— FPr Perf,--
Type of Sample(check only one box)
tM ion Sample(AP) 2.❑Repeat Sample(AP)
Chlorinated:Yes ❑ NO< (from distribution system after ese?.swine)
Unsatisfactory routine lab number:
Chlorine Residual:Total Free -
3.Ground Water Rule Source Sample ——
lS I I I Unsatisfactory routine collect date:
/ /
Chlorinated:Yes No
0 Triggered (A/P)
Chlorine Residual:Total_Free
❑Assessment(A/P)
1.Surface or OWI Raw Source Water Sample(Enumeration) I S I I I
0 fE coil 0 Fecal Aura Yes No
Idl Samde Collected br Information Only;
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
3 Unsatisfactory Total Corm Present and 1 ¶Satisfactory
0 E.co,present 0 E.cod absent
iacterial Density Rauh.Total Cob-form mpni100m1 E.cci mpn/100m1.
Fecal Coliform cfu/100m1.
eplacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
tab Relererce Number
ecerpt Temp,,: Method COUNT/SI9222D
31e Reported no mama rope saq er en s aeramourmo�r u
.na.t.w.ra My ur,aoq Sae der ten byte
APR 0�i Z0intr pow wry hi�errrbilyel3 7ete15wd e
k1 Lab-Unpin a dairy Or sport sorts+r.
G Oroneab mils tor.,to Cr sou war be
- 1 c% ! no.we by to Waylay.nwp Owl vx1 e rot to pars:wog
1J r u..leal pia Ws a Ie,e,col b199.t✓t(Awri...
DON kon 1031.119(rrlr ow Mil 7I