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Home My WebLink AboutWAT2025-00175 - WAT Application - 9/23/2025 I WAT 2025-00175 / `* .,„\ MASON COUNTY ( • COMMUNITY SERVICES Budding,Planning Environmental Health,Community Health 415 N 6'h Street, Bldg 8,Shelton WA 98584. Shelton:(360)427-9670 ext 400 •:• Betfair: (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: S co*1 r1 \ Date: I -6 Z. Mailing Address: Phone: 3 Co --Igo 3 g 1J O Parcel Number: L{ j 3 2.-3 (.0001. o Type of Water System Reason for Application Public/Community Water System (2 or more Building permit connections) ❑ Division of land: D Individual water source (one connection), tt of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ 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) D I am the manager of this water system.The water system has been approved for connection services. connections There are presently connection(s) in use.This will be the ❑ 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 wi setprovide by state ands (these)local regulation.ction(s)without exceeding the limits of the water system or any limits Signature of Water System Manager Date This form may be scanned and available for public view at www.co.masonevisedt.wao�s. )::EH Forms.Drinking Water Individual Water Well • <Water well report(attached to application). Depth SDI it. tg. ,Well capacity Test(attached to application) S qpm >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. 10—Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/olanninq 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) 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-De b tion oChf er Adequacy for Building Permits are satisfied. Additional Growth Management requirements 36.70A RCW. 1 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: Inb ,oW4/1" 9/23/25 Environ. Health: ` Date 2of2 CSD Director. Date WATER WELL REPORT �. ECOLOGYDEPARiMEN1 OI Soo"of intent N0 WE56600 I,Inagua EcAol{<y Well iD Tag No 13Pf195 Type of Work stare of Wathioston Site Well Name(if more than one well) IA CaaNwarioa Water Right Permit/Certificate No ❑ Dacgrnataaiea r� ortsoel irotallatirxi Nt/l N. tialtieaial (butter Name praPasad Use ®Ik*neaei_ q�ita+tcipal iretperty O Deo/arm g C l origami O Tat wen ci of e, Well Sucet Addrem Be ass In P3 New• well Type; 0 r City Sheflon County_—n �New well D Alteration O()firer Cl teard ❑Coble Tool 17 f>aeVenasf Cl Othcr CI[eta Ell:,ir• O hlad•Rtsn" Tax Parcel No 42132.31.0008Q Diaaansimm: Diameter of b.xuyt 6 in.to 59 8 Was a vat tarter approval int this well" 0 Yes '3 No Depth of c mpleted well 59 R If yes,trohat vt8s the vatsartce for', Caesarea* Rim Wall Castes Lieaer Dimmer Frog ito 'hickneu Steel PVC Welded Dimwit tt]WWM IX U F.WM CS I O 6 in o 55 .25 to O U 91 0 Location(see instructions on page 2) 21N Range,....11 C) { C7 in _..._ ry in U 1 U '] I U NE v.•/of the AV_'�a Section 32 'township on _ _ __.__at 0 1 0 O 1 D latitude(Example 47 12345) 47.2t9298 N _...-._,- O I U m. U I ❑ ❑ i — O 1 O to -- ---- ----- I.ongtn,tic(Example:•120.t23d5) -123.21tt08 W or DKantldniaa Procedure pertat tioaa: 0 Yesw ti No Type of txrforator ad DrilMer a t�(�et Karr sad stna4rrc,and the kind and Sus of perforations ia by___to Formation Dascttbe by cola,. aeNr.Siva of am tonal No apes-foramina__ m each tare peaaaalcd,tribal lent one entry fix catch change of (krfisratcd Csont•_,,.`A-to ft beta**roved sursttx nature oldie material sheets if ararasarY iatunis too L'sc additional Ser eras: ®Yes 0 No G tt•t4etas e- Depth 63 d From To Nov MAaChine Works_ - Material I.iatadaeturcr's NameMotiel No •ravel, i• 0 Type er 5. uaaSlot a Brown fine to medium i 8 Diameter S_. Slot size�w from �A m 59 A ftarOpatl Mumtaz Skit swc in from ___A w A Brown fine to medium Si' sand and.ravel,loose 8 14 in o Brown fine to medium sand and 1 : ,hose 14 ZtissailFti�ar Ilk'0 Yes �4o Seer (pact material__ 24 ailment&ptsesd Coro' .8.to 8 moist Srrfaca Seat: let Yes 0 No To obit depot' 18 11 Brawn fine sand,fine to medium multicolored 24 59 Material used in peat Benttxlit gravel,wet bid any Grata contain unusable water^ 0 Yet Et No Type of water! Depth of mat Method of sealing su'dta off Pump: MatnRacturcr's Marne_______--- Type 11 P Pump intake depth. A ikagned!ken tote pin Water Levels: Land-surface Massimo above mean sea test! 350 A Stickup of top assail casino 2 A above ground surface Static water level 20 5 ft bckm top of wall cation Date 7/17/24 An:Oast preow= Ibs-Peg square inch Dale _ Artesian weer is ta+ttoikel In_----(caP'take eft.) Weil Testa: steam`: 4 Was■primping pelf armed' Na 0 Yes . In — Yield__wpm with R.drawdnwa aver Ms Yield gram with .A.Akin...down offer tins Yield gpm with A drradownaim__by, -- RRoe/cove, pan sve,drum(lime tent*ten e is roiled offw sear lesCI IneaSu'Cd from well ' pipe,*aver k.ei) Aster l<.el dater I curt Intce N'ater level folk :hie eyf'.Pmtging tea Nader mei gpm oath R drawdown atke_„^hits Air test 15 gpin ru Ah savor set a 40 ft far 1 tits Data 7(17/24 Amman took spin Start Date 7l17124 Completed Date 7/17124 Tempaatevr of water 52 -F was a chemical analysis muddy ❑Yes El No WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well.and its compliance s,th all Washington well construction standards.Materials used and the information retorted above are our to my hest knowledge and belief !)tilling Company Arcadia Drilling Inc U Diller 3 Truin�c U PE-Print ON Johnsen Address PO Box 1790 Striatum7 City,State,Lip Sheiton,WA 98584 License No. 3441T IF TRAINEE. Sponsor's License No. Contractor's Registration No.ARCADDI098K1 Date 7117 4 Spwnsa'5 Signature — 30 0 c t{NU a 3 1llnir m o/M nsr a/tosta a jormat,please call the Water Resawers Provuot at 160407-6872 Printed wokairoavag lass ear hns}tiott Polo r ettler. Presau with a vetch disability cart call 8714.13-b31(. Printed from son County DW., i Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Ted Dahm Weil Tag*: BPF195 Site Address: Beargrass Lane, Shelton Depth: 59' Date of Test: 7(24/2024 Static: 21.5' Pump Set: 40' TIME GPM LEVEL RECOVERY 1 Min 3 21.8 TIME I LEVEL 2 Min 3 21.8 1 Min 21.5 3 Min 3 21.8 4 Min 3 21.8 5 Min 7.5 21.8 6 Min 7.5 22.1 7 Min 7.5 22.1 8 Min 7.5 22.1 9 Min 7.5 22.1 10 Min 15 22.1 15 Min 15 22.9 20 Min 15 22.9 25 Min 15 22.9 30 Min 15 22.9 ll 35 Min 15 22.9 40 Min 15 22.9 45 Min 15 22.9 50 Min 15 22.9 55 Min 15 22.9 1 Hr 15 22.9 1 Hr 10 Min 15 22.9 II Eal _..i Printed From Mason County DMS Printed from Mason County DMS Vanguard Laboratory 2635 Parkmont Lane SW • e• Olympia,WA 98502 360.967.7010 VANGUAP + Report of Laboratory Analysis LABORATORY Collected by: Davis Pumps Matrix Drinking Water 360-329-2699 Laboratory ID: V250822-7 Sampling Address: Date Sampled: 8/22/25 11:45 111 Beargrass Lane Date Received: 8/22/25 12:14 Shelton,WA 98584 Date Reported: 8/26/2025 Sample ID: 111 Beargrass Lane Analysis Result SDRI, MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V250822-7 Analyst:IT Coliform,Total Negative 1 I MPN/100 mL 1 8/22/25 16:52 L.coli Negative I 1 MPN/100 mL 1 8/22/25 16:52 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 08/26/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 08/26/2025 DF:Dilution Factor gr.A.�- ACCaEDUED 17625:2017 MCL:Maximum Contaminant Level -411Ii loutommoiry Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testingc@i vanguardlaboratory.com l www.vanguardlaboratory.com I of 1