HomeMy WebLinkAboutWAT2025-00148 - WAT Application - 7/15/2025 WAT - ()OH E-',
MASON COUNTY 415 ton.W °i Street
Shelton.WA 98584
Shelton:360-427-9670,Ext.400
Public Health & Human Services i3clfair:360-275-4467,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 accompany this application.
Part 1: Applicant/ Parcel Identification Name of Applicant: 1(1V F1944.44C o/lc ru1�`2/1. Lit Date: 7l tS /1•5
Mailing Address: Pc 30x 1A\ rN,\4 3 Phone: 375'
Parcel Number: 5.102.4 I\ C Y\D
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Er-Building permit t)l�l 2c2-4i
connections) ❑ Division of land:
nr Individual w ter source(one connection), #of Parcels? SPL
Iler Well ❑ Boundary line adjustment
0 Spring/surface water 0 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)
❑ 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.gov
.1 Aid I formy.Drinking Winer kecised OSiOg/2024 Page I of 2
.
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
El/'Water well report(attached to application). Depth U S.3 ft.
13' Well capacity Test(attached to application) 140 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.
12/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
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Part 3: Mason County Community Services Evaluation (staff use only)
gl 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:
�� 8/8/25
Environ. Health: Date i
This form may be scanned and available for public view at www.masoncountywa,gov
Page 2 of2
WATER WELL REPORT ,.,
' '
- DEPARTMENT O" Notice of intent No.WE60077
ECOLOGY Unique Ecology Well ID Tag No.BPS-190
Type of Work: State of v?'zshington
29 Construction Site Well Name(if more than one well)'_
0 Decommission r3 Original installation NO1 No._ Water Right Permit/Certificate No.
Proposers Usr. ®Domestic 0 Industrial 0 Municipal Property Owner Name Nau Family Construction
0 Dewatering 0 Irrigation 0 Test Well 0 Other_
Well Street Address XXX W Little EgyPt Rd
Construction Type: Method:
&New well Li Alteration 0 Driven 0 Jetted 0 Cable Tool City Shellac, County Mason
0 Deepening 0 Other ❑Dug El Air- 0 Mud-Rotary Tax Parcel No.52024-11-90110
Dimensions: Diameter of boring 6 in.,to 136 ft. Was a variance approved for this well? 0 Yes ®No
Depth or completed well 135,3 ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
E3 1 0 8 in. +3 129.9 in. 0 1 0 0 I 0 Location(sec instructions on page 2): ®WWM or 0 E\M9
O I 0 in. in DID 0 I 0 SE'/-'/,of the SW'i.;Section 19 Township 20N Range 4W
❑ 1 ❑ in. — in ❑ 1 ❑ DID
❑ 1 ❑ in. in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example.47.12345)47.21263 --
Longitude(Example:-120.12345)-123.24073
Perforations: 0 Yes 0 No Type of perforator used —
Driller's I-Ai/Construction or Decommission Procedure
No.of perforations_ Size of perforations_ in.by in. Formation.Describe by color,character,size of material and structure,and the kind and
Perforated from ft.to ft below ground surface name of the material in each layer penetrated,with at least one entry for each change of
a Screens: 16 Yes 0 No 0 K-Packer ',=== Depth 128 ft. information. Use additional sheets if necessary
Manufacturer's Name!__ Material From 1'o
Type Model No. — Lt reddish brown cobbles gravel some sand silty clay 0 7
Diameter 6Tele Slot size 16 in from 130 U.to 135.3 ft.
Diameter Slot si,.e in.from ft.to_ft Lt brown cobbles gravel sand silt 7 15
T Lt brown sandy day 15 25
Saud/Filter pack:0 Ycs ®No Size of track material in. Brown cobbles gravel sand silt 25 67
Materials placed from ft.to ft. -- Brown silty clayey sand —_ 67 71
Surface Seal: El Yes 0 No To what depth?16 ft. Gray some gravel sand clayey silt 71 73
Material used in seal BENTONITE CHIPS Gray gravel sand clay 73 80
Did any strata contain unusable water? ❑Yes -s7 No
Type of water? Depth or so _ Greenish gray clay 80 85
Method of sealing strata off _ _ Brown gravel sand clayey silt 85 100
Gray cobbles gravel sand silly clay 100 105
Pump: Manufacturer's Name— Type. Gray some gravel sand silty clay wet 105 114 _
H.P. Pump intake depth: ft. Designed flow rate:_gpiu Gray sand silt water 114 136
Water Levels: Land-surface elevation above mean sea level ___ft.
Stick-up of top of well casing+3 0.above ground surface
Static water level 40 ft below top of well casing Dale 06/26/2025.
Artesian pressure lbs.per square inch Dale _ --
Artesian water is controlled by (cap,valve.etc.)
Weil Tests:
Was a pumping test performed? 6 No 0 Yes cz by whom? t
Yield gpdrawdown_ft drawdown after lies I
Yield gpm with,ft.drawdown after firs
Yield gpm with It.drawdown after _bus.
Recovery data(tune-zero when pump is turned off-.vater level measured from well
top to water level)
Time Water Leeds Time Water Level Time Water Level -
Date of pumping test - — —_-- -
nailer test gprn with ft.drawdown after hrs 1
Air test 40 gpm with stem set at 130 ft.for 1 las r Date 05126t2025 {{
Artesian flow gprn
Temperature of water 'P Was a chemical analysis made', Cl Yes lE No Start Date 06/25/2025 Completed Dale 06/26/2025 _ ,J
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.
El Driller 0 Trainee 0 PE—Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING
Signature �_/. 1 4, lit Address PO BOX 44427 �_
License No.2432 _ City,Slate,Zip TACOMA,WA 98448
iF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.RICHAW 32108 Date 06/30/2025
ECY 050-1-20(Rev 09/18) If you need thi.t document in an alternate format.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.
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Page 1 of 1
Washington State Department of Health
WATER BACTERIOLOGICAL ANALYSIS
Client Name: Nau Family Construction LLC Reference Number: 25-19918
PO BOX 1418 Project: Not Provided
Eatonville, WA 98328
System Name: Repeat Sample Number
System ID Number: Lab Number: 164-39976
DOH Source Number: Field ID:
Sample Type: Date Collected: 6/25/25 13:00
Sample Purpose: Investigative or Other Date Received: 6/26/25
Sample Location: 50 W Little Egypt Wye Rd Shelton WA 98584 Date Set: 6/26/25 11:40
County: Date Analyzed: 6/27/25 9:30
Sampled By: David Nau Report Date: 6/30/25
Sampler Phone: Comment:
Approved By: ckk,mlp
Authorized by:
Ceann K Knox
Lab Manager,Bellingham
DOH# PARAMETER RESULT oea!,fic"UNITS Analyst METHOD Batch COMMENT
1 1TOTAL COLIFORM • Satisfactory,Conforms Absent per t00mt jln SM9223 B • m_250626a
3 E.COLT Absent per 100mL SM9223 B m250626a
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If the sample is unsatisfactory you can get information on well disinfection at Washington State Department of Health
WA DOH:http ://doh.vta.aovicommunify-and-environmef /drinkinci-water/disinfection
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NOTES-
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FORM.c8aci email: nauent@yahoo.com