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Home My WebLink AboutWAT2025-00219/WATER ADEQUACY - WAT Application - 10/27/2025 WAT 2025-0021.9 MASON COUNTY 415 N.6a Street Shelton,WA 98584 eMI, Shelton:360-427-9670,Ext.400 -_ ----= Public Health & Human Services Belfair: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: tiEWEYBALL, NANCY Date: Vy27/2025 Mailing Address: 1830 WEIM-E1M1e M lelft? VVA 98584e: 3606 91( 33353 Parcel Number: 31 N4d7b33 'a icoa, --I 5 - cO033 Type of Water System Reason for Application Cyr Public/Community Water System (2 or more 1E Building permit BLD2025-01 173 connections) 0 Division of land: O 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. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: TITPRAPFrf6WrY Water Facility Inventory (WFI) Number: name (write"none" for two-party) ® I am the manager of this water system. The water system has been approved for 2 services. There are presently 1 connection(s) in use. This will be the 2 connection. O 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 Nancy Dewey Phone 360-490-1353 Signature of Water System Manager �""�h' _" Date 10/2/25 This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems l3 Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report (attached to application). Depth 1 $0 ft. I9 Well capacity Test (attached to application) 13 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. N 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. I 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: 10/27/25 Environ. Health: `RA/Akrove5WA: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE59626 ECOLOGY Unique Ecology Well ID Tag No. BNM813 Type of Work: State of Washington Site Well Name(if more than one well) WELL#1 0 Conswction 0 Decommission i==Ji Original SettaUnion NOI No. Water Right Permit Certificate No. Proposed Use gg Domestic 0 Ind*ittial 0 Municipal Property Owner Name DEWHILL HOMES LLC D Dewascnag ❑4rigatsnt U Test Well 0 Other Well Street Address DUSTY LN Coostruction Type: Method: City SHELTON County MASON Cdi New well U Alteration L Driven L./Jetted ❑Cable Tool 0 Deepening 0 Other Dug M Air- 0 Mud-Rotary Tax Pared No. 319027590033 Dena : Diameter of boring 6 in,to 180 R. Was a variance approved for this well? !Yet No Depth of completed well 180 I If yes,what was the variance for? Comtra ils Details Wall Casing Liner Dauer* From To Thelma Steel PVC Welded Thread p I 0 8 i, +1 170 150 in. ® 1 ❑ 21 I ❑ Location(see instructions on page 2): IR WW!N or 0 E WM ❑ ( ❑ in. ❑ I ❑ ❑ 1 ❑ NE 1/4-1/4of the NE '/. Section 2 Township 19N Range 3 , ❑ 1 ❑ in. . in O I ❑ I n O 1 M in. in ❑ 1 ❑ ❑ 1 7 Latitude(Example::47.12345) 47.16914 Longitude(Example -120.12345) -123.01593 Perrendftatt Cl Yea Cal No Type of perforator used Drifter's l.og/Cometructisa or Dtcoatsailalaa Procedurt No of perforations,_ Size of perforations is by-it' Fora ion Descnbe by coke.chewer.size of material and structure,and the kind and Perforated from R.to_ ft below ground win Lai a nature of the material in each layer pcnetresed,with at kart one entry for each change of I Screens: 'A Yes ❑No ti F:-Packer . Depth_ft. infomuuoo the additional sheen if m:canary. Maaufactunrr`s Name Material From To Type STANLESS Model No. CLAY&SAND SLUE 0 95Diacoem 6 in. Ste size 10 in from 170 ft.to 180 R. Diameter in. Slot sae m.from_R to ft. CLAY&GRAVEL W/WOOD BLUE 95 100 CLAY&GRAVEL BLUE 100 115 Saud/Mier pack:❑Yes fil No Size of pack material_in CLAY&GRAVEL WOOD BLUE 115 130 Materials placed from tt to It CLAY&GRAVEL BLUE 130 160 Surface Seal !y Yes ClNo To what depth? ft. GRAVEL H2O BLUE 160 180 Materi Materal used in teal BENTONITE Did any anus contain tnnnsabk wale? 0 Yes Lll No , ,'.":. Typo of water? Depth of strata Method attesting meta off , Pomp: Manufacturer's Name GOUL.t)$ Type: SUB s N.P.JAR Pump intake depth:1W ft. Designed Bow raw: 15 gpm Water Level*: Land-surface elevation above mean see kvel_ft. Stick-up of top of well casing 1 8,above grourid sirface Stec water level 122 ft.below top of well casing Date 84-25 Artesian prostate lbs,pea square inch Date Artesian water is controlled by (cap.valve,etc.) Well Tara: A Was a pumping trot performed? U No L+!Yes b by whom? Yield 19 gtan with,1 3._ft.drawdown after 4 lire. Yield gprn with ft drawdown after Ivs Yield gnen with a d swdowwn after he. Recovery data(time v zero when pump is turned off-water level roes:c red from well top to water level) Time Water Level Time water Level Time Water level Date of pumping tat Baser rest spat wits_ft dnwdown after he,. Air test win with stem set at_ft-for_-hrs. ^ Date Artesian flow_spine Temperature of watm •F Was a chemical analysis made? LJ Yes J No Start Date 7-21-25 Completed Date 7-30-25 WELL CO"i3TRUCf1ON CERTiFICATION: i constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well 0 consUtrctiott slsnds:da.Materials used and the information reported above are true to my best knowledge and belief. 113 Driller❑yTrraineee 0 PE-Print Name MADI TROTTER Driiling Company COOLWATER DRILLING„INC. Side f Iltl4 Address 10921 NW HOLLY RD License No.3367 City,Stale,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.COOLWDI9410M Date 8-2-25 Printed �y y y.� p ,ECY,OW s2Q k t f tier need this document to anafrernate format,please call the Water Resources Program at 1 1 i I 1 L 'J '131f 4tV-$8 L" hearA g-loas our errl!7/I for ll'id/sirgton Relay Service. Persons with a speech disability can call Printed from Mason County DMS 877 833-6341. COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 360-830-9005 <29 COOLWDI941QM F% �o4 0 CUSTOMER NAME DATE 8-4-25 _ 1 DEWQHILL HOMES LLC CUSTOMER ADDRESS 319027590033 TIME STATIC GPM . TIME STATIC GPM 122 05 133 19 120 136 19 10 136 19 135 136 19 15 1136 19 150 136 19 20 136 19 165 136 19 25 136 19 _ 180 136 19 30 136 19 205 136 19 45 136 19 220 136 19 60 136 19 235 136 19 • 75 136 19 _ 245 136 19 90 136 19 105 136 TIME 19 RECOVERY STATIC RECOVERY STATIC 136 TIME _ 05 122 30 — 10 45 15 60 - 20 75 25 90 Printed From Mason County DMS Printed from Mason County DMS 26276 Twelve jjt Trees LEI NW it Ste-C J1 SPECTRA Laboratories- Kitsap Poulsbo,WA --- , 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Da Sample Collected Time Sample I Cry Collected0 I ! psi i S �."" ,i Aje r YeM na Ya Q+DP" TYe of Water System(check only ore box) 13 Gimp A ❑GroupB iltlihkf *cup A and Group B Systeme-Proode from Water Feditles Ironton/NF4: kilem : 1 usry ( Contact Pinson: Gds.o L i v is fib .6 R a t l.L r( oa/Phoe: 34,6 830- 9.004, 1 Call Male: Bret 1 Eve.Plorw: Swami la for4 Waft Wass 101*calt aeon aew for aria**ewes lr) - e.Doi80* t�y,t•9/8-rLLX/•*(e /'That- (.fiY SAMPLE INFORMATION Semple collided by(name): tOo -Loh,nt, Specie bodkin where sample coisctbd: Special instructions or commonly QOSTy Lr" Type of sari*oack only one boa) 1.❑ Malin DistriblAtoa SmnpI OP) , 2.❑ Repeat Sea*WP) Chlorinated:Yes 0 No❑ Ow dieMbilial W alla serene mu*Yw) th>allail tery roi*e lb number. Chlorin ..,,._Residua Toed_Frss_ i.Ground Misr Rule Sara SampleJ Unsatisfactory routine coiled daft s I sI _ 1 / Ctdorbubd:Yes No 0 Triggered(AR) Chlorine Residue:Tofel Ftee__ ❑Assessment(NI)) d.Swim or GYN Raw Souses Wider Smote(Exxreeredon) I ! l I I 1 0 E.col ❑FearHama Yes H Y,.__No 5. aspi!ceeaied W ed.mrne Pay t..P'Rb amerce L Oxiap ce Rrnai DRINKING WATER RESULTS LAS USE ONLY 01l aaIL edety Totat Cc1tmn Preset and yissSeflebsetesy ❑Ecoipresent D Ewe absent Bacteria Durniy Results:Tote Callon mpn/100m1 E.coi mpnn00rnl. Fecal Colton dullaOnd_ 103C AOnil. Replacement Sample Required: 0 TNTC 0 Saw*bo ad 0 Sample Volans 0 Damaged Container 0 . r r - f6.S-Ct LirT4 'd" °i fraca4rT�0 LI-•C1 .ease �' OT-COUNT/SM922 ��yy�y,./(��y��,,r 1t1#r�ra#i..i r.fNrrwa.�__ . n�siMG L A M�IsAh+Kriir��1/N1AM ?. Ai t 5 rNI 9 r�.r..w# ____ w..,w=.- � �.e.a,�a1771f111M ` 00H Libdarmis t j.•:: 1NA cptiol -- _ IR t.wr0rwaTr.�r+r Mwr..aN.ew Y'V Min IOW//00,0110M.ulb WMIYwYL Print T rn Mason County DMS Printed from Mason County DMS f — . -...._-_ ..__..____ ,rv. __