HomeMy WebLinkAboutWAT2025-00164 - WAT Application - 10/3/2025r ,
���� , MASON COUNTY
IN •1�� 1 COMMUNITY SERVICESWAT
%. f /
�, Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 4002025-UU164
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 jimmy kaneshiro Date: 08/22/2025
Mailing Address: Phone:
Parcel Number: 32022-23-00010
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit
connections) 0 Division of land:
X Individual water source (one connection), #of Parcels? SPL
X Well ❑ Boundary line adjustment
0 Spring/surface water ❑ 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)
0 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.
0 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:1EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
® Water well report (attached to application). Depth_138 ft.
2 Well capacity Test (attached to application) 10 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.
29 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14_ 15_16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date
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:
Atentyvi0 10/3/25
Environ. Health: Date
CSD Director: Date ,
WATER WELL REPORT ' DEPARTMENT OF Notice of Intent No. WE60456
ECOLOGY
Unique Ecology Well ID Tag No. BRR 166
Type of Work: state of Washington
Site Well Name(if more than one well):
O Construction
❑ Decommission r--..> Original installation NOt No. Water Right Permit/Certificate No.
Proposed Use: O Domestic ❑Industrial U Municipal Property Owner Name Jimmy Kaneshiro
❑Dewatering ❑Irrigation 0 Test Well U Other Well Street Address 301 E HIIICrest Dr
Construction Type: Method:
La)New well ❑Alteration U Driven ElJetted ❑Cable Tool City Shelton County Mason
❑Deepening 0 Other U Dug IC Air- ❑Mud-Rotary Tax Parcel No. 32022-23-00010
Dimensions: Diameter of boring 6 in.,to +2 ft.
Was a variance approved for this well? 0 Yes O No
Depth of completed well 138 ft
If yes,what was the variance for?
Conntructimu Details: Wall
Casing Liner Diameter From To 'Thickness Steel PVC Welded Thread
p I ❑ 6 in. +2 138 .25 in. O I 0 D 1 ❑ Location(see instructions on page 2): 0 WWM or 0 EWM
❑ I ❑ in. _ _ in. ❑ I ❑ ❑ 1 ❑ SW '/.-%of the NW 'V:;Section 22 Tnnmship 20N Range 03
❑ 1 ❑ in. _ in. ❑ I 0 0 I ❑
❑ 1 n in. in. ❑ I O ❑ I ❑ Latitude(Example:47.12345) 47.21057
Longitude(Example:-120.12345) -123.05493
L
p Perforations: ❑Yes A No Type of perforator used Driller's Log/Construction or Decommission Procedure
y No.of pw rfo rumens Size of perforations in.by__in. Formation:Describe by color,character,size of material and structure,and the kind and
L Perforated horn R.to fl.below ground sat!lice
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: ❑Yes 0 No 0 K-Packer r' Depth-R. iufonmmtion Ilse additional streets if necessary.
n Manufacturer's Name Material From To
C. Type Model No.- 0 1
Top soil
Diameter_ in. Slot size in.front ft.to ft. 1 4
p Diameter in. Slot size in.from R.to-R. Clay,silt,brown/hard
c. Fine sand,silt,some gravel,brown/soft 4 39
6 Sand/Filter pack:U Yet No Size material pack atcrial in' Very fine sand,sill,some clay layer,gray/hard 39 86
o Materials placed front R.to R• Sand,fine,silt,gravel,gray/hard 86 109
E Surface Seal: 0 Yes ❑No To what depth? 18 R. Sand,gravel,silt,medium to large gravel
o
Material used in scat Bentonite Chips
gray/hard 109 140
C Did any strata contain unusable water? 0 Yes EC No
L Depth of strata
0 Typeof water? Department of Ecology
p method of sealing strata off
C
0 Pump: Manufacturer's Name N/A Type:
0 11.1'. Pump intake depth: ft. Designed flow rate: gpnt .1(f1 .J 1 2025
3 Water Levels: Land-surface elevation above mean sea level fl. !L�I 1
y Stick-up of top of well casing +2 It above ground surface
r.- Static winter level 60 R.below top of well casing Date 7/28/2025 for Rracnt Ifr:FlR PrnaP:lit7
Artesian pressure lbs.per square inch Date
C Artesian water is controlled by (cap,valve,etc.)
0
L
L Well Tests:
0
3 Was a pumping test performed? fgl No 0 Yes c> by wham?
Yield gptn with_R.drawdown after_hrs.
7) Yield spin with Il.drawdown after hrs.
Yield gpnr with_R.drawdown after-hrs.
zr
o Recovery data(time-zero when pump is hared off-water level measured from well
O lop to water level)
>. Time Water Level Time Water Level Time Water Level
5
U
U -
Date of pumping test
Bailer test pmwith_fl.drawdown alter_hrs.
0 Air test 35 gpm with stem set at 136 II.for 1 hrs. - Date 7/28/2025
EArtesian flow gum
L
Temperature of water °F Was a chemical analysis made? ❑Yes 0 No Start Date 7/28/2025 Completed Date 7/28/2025
O
to WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
3 construction standards.Materials used and the information reported above arc true to my best knowledge and belief.
to
C
- O Driller 0 Trainee❑PE-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature tT_ ' ; Lze^r,,&I.„_ Address 1162 NW State Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 7/29/2025
ECY 050-1-20(Rev 1 l/I 8) If you need this document in an alternate format,please call the Water Resources Program at
360-407-6872. Persons with hearing loss can call 71 I for Washington Relay Service. Persons with a.speech disability can call
877-833-6341.
MOERKE & SONS PUMP & DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805
PUMP TEST
JIMMY KANESHIRO C/O CLAYTON HOMES 9/30/2025
301 E HILLCREST DR
SHELTON, WA 98584
WELL SITE ADDRESS: 301 E HILLCREST DR, SHELTON
Pump Make & Model: Pump Set At:
Sounder Make & Model:
Make & Model: Measured in: GALLONS
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 0 248952 55'
1 12 248964 55'
2 12 248976 58'
3 12 248988 58'
4 12 249000 60'
5 12 249012 65'
6 12 249024 70'
7 12 249036 75'
8 12 249048 80'
9 12 249060 80'
10 12 249072 80'
15 10 249122 80'
20 10 249172 85'
25 10 249222 93'
30 10 249272 93'
35 10 249322 93'
40 10 249372 93'
45 10 249422 93'
50
55
0 93' RECOVERY
1 89'
2 83'
3 77'
4 73'
5 69'
6 65'
7 53'
8 61'
9 58'
10 56'
15 55'
SIGNATURE:
4,,,;.-. rit7 . •. P AND DRILLING
Vanguard Laboratory
k. 2635 Parkmont Lane SW,Suite A
Olympia WA 98502
vf.,VAN r --- 360_967-7010
GN021 I F04 l COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
' Collected
51 i11 i �5' ❑nM (1�naa
J/
d- •m
--
DirPhl
Month Day Year
Type of Water System(check only one box) (� .{�
0 Group A 0 Group B IA Other``' ` -.
Group A and Group B Systems-Provide:from Writer Facilities Inventory(WFI):
1; IDU _ -- — - ___ - - - .
• System Name: 0't M °LAOStiif() __
Contact Person: Co\(` t /
Day Phone:( lg0) Cell Phone:( )
Email: Eve.Phone:( )
Send resuRs to:(Print fell name,address and zip code or e-mall)
\1(Q - W\A1 S ce/
Cj‘A,eV,CS We(
i
. SAMPLE INFORMATION _
Sample collected by(name):atA4
Specific beano w(:ere sample collected: Spacial Iin t cUons orrents:
3dl t: ►(1 -- pc
5 tWA-_ 1 , .
TypC of Sample(select only One_type of sample from types 1 through S below)
i.❑Routine Distribution Sample(ANP) 2 0 Repeat Sample(ATP)
(from dlstribtNon system after unsaL routine)
Chlotinated:Yes No Unsatisfactory routine lab number:
• Chlorine Residual:Total_,Free -J
3.Ground Water Rule Source Samplb Unsafisfactoty routine collect date:
IS I i_ _J._- -
Chlorinated:Yes__ No
❑Triggered(AfP) Chlorine Residual:Total__,Free__--
❑Assessment(NP) —_
4. Surface or GWI Raw Source Water Sample(Enumeration) l S 1 1 1
1 ❑E.coil 0 Fecal FlRertd Yes .No
5.(Sample Coaecied for Information Only: _
LAB USEONLY DRINKING WATER RESULTS ' .CAB USE.ONLY
❑Unsatisfactory Total Ccldorm Present and D4 Satisfactory
❑E.coli present 0 F.coliabsent ^[
Bacterial Density Results:Total Colifomt 1100mt, E.coli . I1Q0m1, . .
Fecal Coliform_ _11o0m1. HPC ___/1 ml.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
Dateffirrio Relived: Lab Reference Number
. —Receipt
a.5__\1R1 ., O%\\-\S
Receipt Temp C: Method Code:
S't\ 23'Pi3
Date Reputed fo DOH Lob Use Only:
DOfi Lab-Samplell
285-1)\\\5 j
1 _,_,M .. r .ecosrsazrmxmYFtrru.
Vanguard Laboratory ,
2635 Parkrnont Lane SW,Suite A *'"
Olympia WA 98502 VANGUARD
360 967-7010 LAno6ATOOY
Nitrate/Nitrite
. Analysis Report
S stem Grou s T pe:(Circle one.) A B �?DM
H
ate Collected: (MM/DD/ System Name:-'t,y ti c—�
ater 5 stem ID Number:
— S Court :(�(� �
ab Number/Sam le Number:_ I / ,- \ 3_ Source Number(s) (List oil sources if blended or cornposited.)
ample Location COt E iUGto �r
Date Received: (MM/oD/vY) 0 v La.
ample Purpose (check appropriate box) /2 5
Date Analyzed: (MM/DD/YY) .(L
❑ RC—Routine/Compliance (Satisfies monitoring requirements.} pate Reported: (MM/D[�M) �. 8/1 4-/ 5
❑ C—Confirmation(Confirmation of chemicalresult.)• -_-`
PI I—Investigative(Does not satisfy monitoring requirements.) COMMENTS: V ���� S
❑ O—Other(specify—does not satisfy monitoring requirements.) ___ Pre treatment/Untreated (Raw)
Sample Composition(Check appropriate box.) Sample Type(Check one.)
Source
g] S—SingleElPost-treatment(Finished)
❑ ❑Unknown or Other
B—Blended (list source numbers in"Source Numbers"field.) Sample Collected by: (name) � '1�'
•
❑ C—Composite(List source numbers in"Source Numbers"field.) phone Number: .. ro --
❑ p—Distribution Sample __ -- Bill to: (Client name.)
Send Report to:fti3gii:iiiii
f c�5 _ _. '1
3 dw5 _------_ - _
Analytical Results
i Exceeds MCL? Method/
Data
•
m9/L—_— Hach 1020G
DOH i Contaminant Qualifier Results MRL 0.5 5.0 10.0 L SDRL Tri••er MCL Units (X if Yes Initials
0020 Nitrate N ��
NOTES
*Confirmation:Include the original lab number,sample number,and collection date of original sample in either comment section.
• --No trigger value for combined nitrate plus nitrite.
•
Data Qualifier:A symbol or letter to denote additional information about the result.
DOH#:Department assigned contaminant number.
Exceeds MCL(Maximum Contaminant Level): Marked i t he ccontt theaminant
amoYnmensde xcoeds ed thteMCL regionalunder cf ice t your 246-290 and 246-
rea.
291 WAC. If you have questions about this result,please
METHOD/INITIALS:Analytical method used/Initials of the analyst that performed the analysis.
mg/L:milligrams per liter or parts per million.
MRL(Method Reporting Limit):The lowest quantifiable concentration of a contaminant.
SDRL(State Detection Reporting Limit):The minimum reportable detection of a contaminant as established by the department.
• Trigger:The department's drinking water
response
nse level.Systems
with contaminants detected at concentrations at or above this level
may be required to take additional samples l
LAB COMMENTS
1 Revised December 2021