Loading...
HomeMy WebLinkAboutWAT2025-00174 - WAT Application - 9/9/2025 WAT?0G -ioiI 1 MASON COUNTY Shelton, � 8584 rr Shelton,ll'A 98584- 0" Public Health & Human Services Belton:360-475-4467,Ext.400 Belfair:3G0-275-44G7,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. i 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 Nancy Dewey Name of Applicant: Date: 6/24/25 Mailing Address: 1830 F Rrockdale Rd Phone: 360-490-1353 4 Parcel Number: 31902-75-90032 r/icci) Type of Water System Reason for Application (F J"'�°' O Public/Community Water System(2 or more M Building permit Tji4.�Vi J6-- t 7te—"f connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL O Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) W Other(explain)2-party well ❑ 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 OYUelf160, I Complete the section appropriate for the type of water connection being evaluated: VI I— Public Water System Name of Water System: t`JL 6 l L�{} "t t. Water Facility Inventory(WFI)Number: ' 1111Z\ . (write"none°for two-party) ):C( I am the manager of this water system. The water system has been approved for r services.There are presently -- f connection(s)in use.This will be the I 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 \(.Ullu,t{ 17(t.�1t-� Phone �3��' �w' Signature of Water System Manager r 1 C 6 LS g Y 9 ,f� 11 t,a„1-(/ � O,t-vt=t� Date �- j- 2 This form may be scanned and available for public view at www.masoncountywa.gov J:\FH Fonns\Drinking Water Revised 05/08/2024 Page I of 2 T?o O1 Group B Water Systems D Satisfactory bacteriological test within last year(attach to application). Individual Water Well 14 t. 70 ?i-QDa , ' Water well report (attached to application). Depth 176 ft. ���Q l G©z} Well capacity Test(attached to application) L D??:{ gprn FOt1 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. (70( 075 ir Satisfactory bacteriological test within last year(attach to application). gf ZS jzo?5-- Individual Spring/Surface Water 9 ❑ 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) 1,X1Satisfactory 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. 1- Unsatisfactory Determination: • ��jj Applicant's water supply does not appear adequate to meet the needs of its intended use for ttr'ecif311gwing G reason(s). •c". ! 28421, 1 F 0<? • Reviewer's Signatures:i — (O( ( ,,ar����`y£ • Environ. Health: Date �ft 40.. • • This form may be scanned and available for public view at www.masoncountywa.gov i'aee 2 of 2 l W A ca0µ'i_ViVINTI W°" a \ao2^15 90031 2 13.2$ I'. � At i'A1t�. 3 <---10 f--:-- 41f. t Ai.. : , r...7.1. Alkl' lid ;;` O*_► 11 1 tIN M 1 t, 111i ; 11 N atco3�o r Ii S 0 ' 0, s= PhULA JOY J0N11S0� 1)}, Q® o a b SiG'� � , N co, 'I :51 7 , r- � y -•... T ......__ ,,.,. 6,..on 30, 4Q 1N;v,, ,,s. t- p 4 to ow:, , 00), .,,,, • v.,. ..„, i Jr- Zcoco.S8 0GAeea wF.t.t + ` FA 1MlI-2 D.F, (3� 3 x�O� � • 5GF1�E- 10 1 -t-R.�Ne.t-k-S@ ' ' 6 . . p lc, a, (.o So v_t2vv i/l eE E.E ti w t-t�- fZF.� 1 SLOT Pt"Ar)J %)rGla- *l t- L ViC) M.1~S Key; ?A 310 z-T - 900 3Z O Audio-Visual Alarm • Ei Sttv-LlON U>) q$ 84 O Cleanout 11 33 500 Gallon Pre-Trash tank 1 'TEST �UL; O NuWater BNR-500 MU Tank { 4 Nu�ta I! " SAND -j- ! p F I k : -3` Lp{ U Z O 1,000 Gallon Pump Chamber ,ice ' !-D f� sat4t) T o va 5-r w, .......mot:-xv,-..• 1 t^ �1 OG Valve Control Box {; SPtO o) 0,2,00 321, AP ROVED JUL 08 2025 MASON COUFin E'�Ylrc4`i!��NTAL HEALTH RAT Print �A8m Mason ounty L s (.3,..-,R) 1 �nnteci horn Meson County t?MB ir MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON: ,S 42 TON,I,EXT 400 584 �14 BELFAIR:360-275-4467,EXT 400 1 i Public Health & Human Services ELMA:360-482-5269,EXT400 FAX:360-427-7787 10/15/2025 DEWEY NANCY 1830 E BROCKDALE RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00096 XX SE Dusty Ln 319027590031 The 2-party water system, The Olympic (319027590031/319027590032), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater management around the water source. If you have any questions, please contact me at 360-427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely David Anderson Environmental Health Specialist Mason County Environmental Health t` _ DEPARTMENT Of NoticeoflntentNo. WE60253 7e©e WATER WELL REPORT - , �� _- ECOLOGY Unique Ecology Well ID Tag No. BNM814 Type of Work: State of Washington ID Construction Site Well Name(if more than one well): #2 WELL . ❑ Decommission : Original installation NO1 No. Wafer Right Permit/Ced ificate No. Proposed Use: L Domestic ❑lydusnial ❑Municipal Property Owner Name DEWHILL HOMES ❑Dewotering ❑Irrigation (7 Test Well LI Other Well Street Address DUSTY LN Construction Type: Method: City SHELTON County MASON Is)New well U Alteration U Driven ❑Jetted 0 Cable Tool LI Deepening U Other I]Dug IE]Air- 0 Mud-Rotary Tax Parcel No. 319027590031 Dimensions: Diameter of boring 6 in,to 170 n. \Vas a variance approved for this well? ❑Yes O No Depth of completed well 170 ft. If yes,what vvas the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I 0 6 in. +1 160 .250 in. CI I 0 O I 0 Location(see instructions on page 2): IJ WWM or 0 E\VM ❑ I 0 in. _ _ in. U I 0 0 I 0 NE 'A-%ofthe NE /;Section 2 Township 19N Range 3 p 1 0 in. _._._ _in. ❑ 1 ❑ ❑ I ❑❑ I ❑ in. in. ❑ ( ❑ O I O Latitude(Example:47.12345) 47.17014 _ Longitude(Example:-120.12345) -123.01642 Perforations: U Yes L No Type of perforator used , Size of perforations in b in Drillers Log/Construction or Decommission Procedure Na.of perforations_ P >— Formation:Describe by color,character,size of material and structure,and the kind and Perforated from_R.to_ft.below around surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: U Yes ❑No R K-Packer r ' Depth_R. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type STANLESS Model No — CLAY&GRAVEL BROWN 0 55 Diameter 6 in Slot size 10 in from 160 ft.to 170 ft 55 65 Diameter in Slot size in front ft.to ft. CLAY&GRAVEL BLUE CLAY&GRAVEL BROWN 65 80 Sand/Filter pack:0 Yes Wa No Size of pack rateral in CLAY&GRAVEL BLUE 80 115 Materials placed from ft.to ft. CLAY GREEN 115 138 Surface Sul: IC Yes ❑No To what depth? 20 n. CLAY&GRAVEL BLUE 138 158 Ateterial used in seal BENTONITE SAND&GRAVEL H2O BLUE 158 170 Did any strata contain unusable water? 0 Yes 13 No Type of water? Depth of strata Method of seating strata off Pump: Manufacturer's Name GOULDS Type: SUB 11.P.,1 it Pump intake depth:104 R Designed now rate: 11 a+ gpm Water Levels: l.andaumfaco elevation above mean sea level ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 127 ft.below top of well casing Date 8.20.25 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? fl No F.Yes c' by whom? Yield 20 gpm with 1 R.drawdown after 4 Ins. Yield _gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time—zero when pump is turned off• water level measured from welt top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test — Bailer test gpm with_ft.drawdown after_Ins. Air test gpm with stem sal at_ft.for hrs. L Date Artesian flow gpm Temperature of water *I' Was a chemical analysis made? U Yes L•1 No Start Date 8-4-25 Completed Date 8-18-25 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. ()Driller❑Trainee 0 PE—Print Name MADI TROTTER Drilling Company COOLWATER DRILLING,INC. Signature MA- -- Address 10921 NW HOLLY RD License No. 3367 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.COOLW01941QM Date 2-21-25 ECY 050-1-20(Rev 11/18) If you need this document in an alternate formal,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. i COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 �, 360-830-9005 406.2 -v COOLWDI941QM 44. 9425 `Fp CUSTOMER NAME DATE 8-20-25 DEWHILL HOMES LLC #2 , CUSTOMER ADDRESS I 319027590031 3 TIME STATIC GPM TIME STATIC GPM 127 05 128 20 120 128 20 rt 10 128 20 135 128 20 15 128 20 150 128 20 20 128 20 165 128 20 25 128 20 180 128 20 • 30 128 20 205 128 20 45 128 20 220 128 20 60 128 20 235 128 20 ", 75 128 20 245 128 20 90 128 20 105 128 20 RECOVERY STATIC RECOVERY STATIC TIME 128 TIME I 05 127 30 10 - 45 15 60 20 75 • 25 90 I 26276 Twelve` , Trees Ln NW 1 Ste.0 1` SPN'C'I'RA Luburirluc,rt Kitsup Poulsbo,WA —Where e$Uienetaaalltl_ 98370 (360)779-51e1 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County �e 12s1,2 �qj�Collected o ypt .�Sv'` ��-?, Na1M Dal 'u /S._•._ �w 1 Type of Water System(check only one box) �CF/�j�O '<f ❑Group A ❑Group B )titer _ Group A and Group B Systems-Provide from Water Fa hies Inventory(WF1): ID% Stem Name Contact Person: ' 0-7-40 Qt .. _ //:`we __-- Day Phone: 340•— Q$0 " pD Cell Phone: _ _ — Email: II Eve.Phone: -__ Send results te:(PMlAllllaare,Went aiddetod'a'null therefor*UtuoI1 copy°moon) SAMPLE INFORMATION Sample rnkcled by(name):et. pvefiz5 Specific location where sample co acted: f Special instructions or comments: O y L,..1� lk Z Type of Sample(check only one box) 1.❑Routine Distribution Sample(AR) I mat. Sample(AIP)(tom Chlorinated:Yes ❑ No❑ dstrib Lion system after at.roam) Unsatisfactory routine lab number: Chlorine Residual:Total—Free_. 3,Ground Water Rule Source Sample l Unsatisfactory routine coOecl dale: I s 1 1 / I Chlorinated:Yes No 0 Triggered(NP) Chlorine Residual:Total Free_ 1 ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) ( S 1 l ❑ r�.cob ❑Fecal hued Ye'_No_ ` i 5 / ample Collected for information Only. LI Private Redden°, U C Rye LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total CokfoeTn Present and yerq,atisfactory ❑E.cokpresent ❑E.coriabsent • Bacterial Density Results:TotalCokfoim mpnlloOml.E.coi mpN100d. Fecal Coldonn cfu1100m1. HPC. _ chr/tml. Replacement Sample Required: ❑TNTC 0 Sample too old _ ~ ❑ SampleVohrme 0 Damaged Container la__ — — Lab Reference�` —....��— Temp kelledCode: Receipt SM9223? OT.000NTI SM92220 �-�� "�'�� n setestlf fat' u/err'e rwmeotayirrll D, ? 510a5 Dare) 2 G dn.tYafiteauaarrr.e ttgfryvda7osrlvAa Nn.,:, Lq '- I+e N111diritln l+old(rw ran rou`ed Kirsrale ess+r•rbr1e royr N uvr irseC.aYrM Ya17/iS1a I lnr _�....___... ..._ hskryitis romi pourer. DOH Lab-Sample a CI �(/�/,) Rafe mt.&rife try me tool Na u e♦dto m{NiU/s 010• t ) "" 0 rq}.1C tyro Lk. ri.1111 ropl oho!of to ropolLod I two t/ / CIA ri aito<.tos/...to*peal q a.-rL,I.*Dr dolei —OM Rom1M1 19 McNw PJ171