HomeMy WebLinkAboutWAT2025-00143 - WAT Application - 6/28/2025i
" '' I wAI--2025-00143
MASON COUNTY -
,•tt1 ry COMMUNITY SERVICES
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415 N 6'1'Street Bldg 8 Shelton WA 98584,
Shelton (360)421-9670 ext 400 •:• Belfair t360)275-4467 ext 400 •:• Efma (360)482.5269 ext 400
FAX(360)427-7767
Application for Determination of Water Adequacy
Instructions _ ___
t Complete Part 1. No determination can be made until Part 1 m 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
11 Alt a oved buitdrn site plan must accompany this application
Part 1: Applicant/ Parcel Identification
Name on Applicant: ' bt't k kfteSS k r t ,1 Date riit .'n I.::: --
Mailing Address '�yQ0 NE U,1't1'6,� 'S U h 1)-,, Phone 31c 0 )o l- 15�2(�.
Parcel Number. ;22,. ._50 _ f 0 0414
Type of Water System Reason for Application
IS Public/Community Water System(2 or more Building permit
connections) 0 Division of land.
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
O 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
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 07/16/2025 Two party well shared
with neighbor
Complete the section appropriate for the type of water connection being evaluated WEL2024-00022
Public Water System
Name of Water System t T-c LL\k-- —Fro c.+ `ref £ 43
Water Facility Inventory(WFI)Number iV+r✓ne.,
I (write'none'for two-party)
iC3 I am the manager of this water system. The water system has been approved for services.
1 There are presently connection(s)in use This wilt be the connection
X5 i am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system(re. recreational to full time)..Please indicate on the following line the nature
! of this change C,r,iNcc t v„1A-e r +- r- - i�1Asi/tit 0"ti)
This water system is able and willing to provide water to this(these)connection(s)without exceeding
I The limits of the water system or any Omits set by state and local regulation
•
Signature of Water System Manager -- ---- Date cal% l�ti
This form may be scanned and available for public view at www.co,mason,wm .
J.Tit Navy Lkinkaq;>..tcf Rolsai I Z. :“I s
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
d
VJ Water well report(attached to application). Depth 51 ft.
>400
® Well capacity Test (attached to application) 20 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.
M Satisfactory bacteriological test within last year(attach to application).
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
• •
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:
Environ. Health
�Sl1�l� Date 7/16/25
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 o
fMen Cent Ma AL 39
1 Rh•w w'' Idteaaropywithoology WATER WELL REPORTUNIOLIE NAL t.a.1 MG 300
p ermne ow—Omen Copy STATE OF WASHINGTON � Items tad
Thins Copy—D ws copy
(1) OWl4ER: Maim 1)BV1d MAyer__...___.. --- ,a►s.. 14701 SE 232nd St., Icents W& 8042-3812
23 ri R 3W wee
i> . SW ,se SE us see 35 •.�
�; (2) LOCATION OF WELL: corer Mason
1.
(2A) smart ADDRESS OF WELL*name amen' NE 2161 Tee Lake Rd., Tahuya, WA 98588
1� WELL LOG or ABANDONMENT PROCEDURE OES:R{PTION
(3) PROPOSED USE: CI Industrial ID hkrt'ctet (.1 ( )
Test Wei 0 Other ❑ Gorwason•Demos by odor.dr.eaoer.ads of nr. rd.etnelraa C warters
❑ t)eut.er arilbh.lungandraw"d Sr netted kr etch whale. •
Omura nunrlb.al viol dirge d inbrrt�orr To---
(4) TYPE OF WORK. Omura mws E W one) MAMA. —
librrearo❑ Deepened `YM'
Neepoac a:g i Deane
a.00nasonadC Rotary JAW _Brown co >zl rate 0 8.._.
(5) DIMENSIONS: Daiwa or wee 6 .tattoo
orillad 51 'set depth of otetplittat awl 51 rt. Gray hardpan 8 47
(6) CONSTRUCTION DETAILS: Sand & gravel with water 47 51
Casing lnceidi.d: _6_,.___• Own.worn^_SL__e.as__ _46 L
01Ya,trdne R.as R —
Ursa
TAneded r-� • Cent tram I.to It.Z•Ortotatielte: YeaJ lip IL`J .•
Typed prlreror amid _ -
tell d peroration. el.by _—T_�_in.
prtofions Moe R to a.
ps tol*OrM tees t to R .
Pulanloruttom —_ A to IL ,
SC:Wm Yee Cii No❑
aa«,wcvr{term' Cook - — '
Type ;rainless ''ire wrap Modal Mo.
Corm 5 Scot Pas 2 hero 46 It.to 51 n
t.to R ` r,— 1
Dorm _dot wise trap t '—
orerel*tweet: rite G tb C]- Sae at t ► D N S u
Onset pieced Men it tot
stow. roe® No❑ To ow&vet? 18 L \ DEr 0 1 �771 hs
taelsrW u ed in sad RPtnnite •
_ '_. -
Ord any strata contain uncivil*wets? Yes 0 No E t
Typedrrewr7 0e�'dand'a SFRIAU ASSISTANCE CENT;r .. , _
taeerod d sMIMp.a7ta oft -- -
— .—
(7) PUMP: urxderes ra Bees Goulds H.P.o
TM*,
($) WATER LEVELS: 1-'na«'d.°'Nn"wl°" Work Storied 10/27191_,ts. c«drw L.s.d 1 6 -? la_
actor.nr.n sad Ise.b rt_
stark troy 10 ft e.w.wsrw Oslo WELL CONSTRUCTOR CENmFICATION-
auwan Pr ss.ua w rat KOOS irch Dees
Merin wow.cassaba tw I oorptruCteff ardior accept responsibility for aorxtucaon d chit mil,and rts
toad,wee.sic 1 compliance wph al Washington welt construction etsndar 1tl eletenale used dad
the intonaari sr*la
on reporled abase s w to eery bed knw, wd0e and beief-
(D) WELL TESTS: Orawdown oramour%weir WNW Is lowered below woe writ
Was a pump rest wadi?w.3 No a tl pea bad whom?_._.__ NAME _ Davis Dri 11 __
Yield: 9r.tenin.wilt k drawdown der On. id�t( ffi61SPCA4fSt)A, 1;$41~1
Address Belffaai�r� WA 98528
Recovery data(gate teen es owe when pump turned o111(WSW Wei mewed from wet
(spn.d) _�_" ` ". -�---Were. 1.992
asp to water eve)
'ties WsW lava Taal Wait Level TMS Water Level Contractor's
_ VISDI1100A Dare Nov._ to 97
(USE ADDITIONAL SHEETS IF NECESSARY)
baba or wet ---
Baia ter 10 gaiintr.wian 10 M,draw down attar 1 he's,
/urban _ poi:that with sewn ast at -._._- N.far an, Ecology is an Equal Opportunity and Atfrmative Actin.r e 'player.For ape
d t
OW
al accommodation needs.contact the Water Resources Program at(206)
Artasasn tow xe. -.,tt. Date ' Y 407 6600.The TOO number is(206)407-6006
Pllpt froL. - - - _--- - _._...
solomew
•
•
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DAVIS DRILLING
340 NE Davis Farm Rd
Belfair, WA 98528 •
•
lest pump for: David Mayer
Well address:2161 NE Tee Lake Rd,Tahuya WA 98588
Pump: Ya hp
i
Well Depth: 51'
Static Level: 5.6'
Date: 3/25/2024
Weil ID: AAG 300 •
"' Draw Down
Time Water Level GPM
0 min 5.6' 0
5 min 30.8' 25
10 min 35.5' 20
30 min 37.1' 20
1 hr 37.1' 20
2hr 37.1' 20
Recover
Time Water Level
0 min 37.1'
1 min 21.8'
2 min 16.6'
3 min 13.1'
4 min 12.9'
5 min 12.7'
10 min 12.2'
lhr 5.6'
•
Printed From Mason County DMS
Printed from Meson County DMS
•
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Thurston County Environmental Health
a\s'l 412 Lilly Rd NE 4 Olympia,WA 98506
360 867-2.631
71lUR.C1UN COUNTY
COLIFORM BACTERIA ANALYSIS
Dille Sample Collected Time Sample County
Collected
ii l 11-126 adA
WW1 Oar Vox ---.J"pm ����
Type of Water System(check only one box) 0 Private Household
0 Group A 0 Group B 12 Other o f j
I Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IN
System Name
Contact Person. Qubte#' (4ChkeSs`1J
Day Phone:(910 ) ?too�{'t$1t Cell Phone;(310 ) -11{'J(rr
E-mail K.TT thtrG59ie C•(.Liy, Eve.Phone:( )
• Send results to.(Prim full name,address and zip code x email address)
SAMPLE INFORMATION
Sample collected by(name) �O ,1' 4k Whe SS j
Specific location or address where sample collected. I Special instructions or comments:
'1-i41 I,*Tee,Ls.kc-P•c
Type of Sa ple(must check only one box of#1 through#4 tested below)
1.DS Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No _ 0 Distribution System
Chlorine Residual:Total. -Free__ Chlorinated:Yes No_...___...
3.Raw Water Source Sample Chlorin Residual:Total Free-_._
❑E.Coll-GWR(NP)
❑Fecal-space,owl srrwys ournentan Unsatisfactory routine lab number.
Hiered-Yes.. ..No,,.,,,.___.
0 Assessment Monitoring(A/P) Unsatisfactory
nutine collect date:
❑Other / / ..___.___
3 _ s I I
- 1
4.0 Sample Collected for tnformation Only
investigative__ .. Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Colifonn Present and s! tisfactory
` ❑E.094 present 0 E colt absent •«•liform detected
Replacement Sample Required:
l 0 Sample too old(>30 hours) 0 TNTC 0
Bacterial Density Results Total Cotiform,._._.. I100m1. E o _.._ _1100mt. I
Fecal Cobtorm_.....-._._..__.._...i100m1 Entetocoai _.. _/rr1�0,,0,,M.
Method Code 0 SM 92238 ❑SM 9222D Dose and Time Recervod�.<
❑SM 92158 0 Enteroler/E C i-2 3' i I il'
Date e w Time Analyzed ' )• "Z We itep xleo 1's+•j
TN:r' i i nusibirPMew do" tab File�Y R'.JeNt Ne�� N i
0 8 o b tAiti o 44
I