HomeMy WebLinkAboutWAT2025-00205 - WAT Application - 11/4/2025r ._
W AT 2025-00205
415 N.6th Street
, , ,_.
, .
Shelton.WA 98584
MASON COUNTY Shelton:360-427-9670.Ext.dal
11,.,ss,,. 1041 .:,.. COMMUNITY SERVICES 13el1iii i:36o.275 s467. xt.400
&uldmg Planning.Envvonmental Health.(omrnumty Health
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: GNco 5 A L.+,t (ZEAL f.)1 t '01.-0:. LCLDate: i 010 No ZA"
Mailing Address: 71S3o tar :-iiL S4. cjerti.h.�;t.,.l Licroj hone: L� ) c s 6 i7.I
Parcel Number. ZZ.ZO ti - 7S`- 1 o 2-3 t
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Ii0 Building permit
connections) 0 Division of land:
4 Individual water source (one connection), #of Parcels? SPL
Ll Well 0 Boundary line adjustment
0 Spring/surface water 0 Other (explain)
❑ 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:
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.
'..,.:
JAM Fonns'\.Drinking Water Revised 4/412018
Individual Water Well
$1 Water well report (attached to application). Depth I I(. ft.
Xi Well capacity Test(attached to application)
I S 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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http:/!gis.co.mason.waus/plannrnq 14 15 'S 16 22__
Water use or limitation recorded . N/A Yes
Well Drilled ................... ... . .............. .. Date `_ i �'-� 5
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
O 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:
'?Ar P A'NYA 1" 11/4/2025
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2„r ,
WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE61102
ECOLOGY Unique Ecology Well ID Tag No. BRR 194
Type of Work: State of Washington
Site Well Name(if more than one well):
CI Construction
0 Decommission => Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: 111 Domestic 0 Industrial ❑Municipal Property Owner Name Chrysalis Real Estate Lie
0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 1301 NE Tahuva River Dr
Construction Type: Method: City Belfair County Mason
a0 New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool
❑Deepening ❑Other 0 Dug I]Air- 0 Mud-Rotary Tax Parcel No. 22206-75-90231
Dimensions: Diameter of boring 6 in.,to 117 fl. Was a variance approved for this well? Cl Yes O No
Depth of completed well 110 fl.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread ❑. WWM or 0 EWM
CI I 0 6 in +1 110 .25 in. O 1 ❑ ❑ I ❑ Location(see instructions on page 2):
DIO in. in. ❑ I ❑ ❑ 1 ❑ SW ''%' of the NW 1/4;Section 05 Township 22N Range 02
❑ 1 ❑ in _ in. ❑ I ❑ DID Latitude(Example:47.12345) 47.42584
❑ I ❑ in. in' ❑ I ❑ ❑ I ❑
Longitude(Example:-120.12345) -122.96917
Perforations: 0 Yes 0 No Type of perforator used Driller's Log/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 nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes O No 0 K-Packer : Depth_ft. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No. Top soil,gravel 0 1
Diameter_ in. Slot size_ in.from ft.to_ft. Sand,o gravel,silt,brown/soft 1 4
Diameter_ in. Slot size_ in.from_ft.to_ft. Clay,silt,sand,brown/hard 4 15
Sand/Filter pack:0 Yes E No Size of pack material_in. Sand,gravel,silt,brown/soft 15 49
Materials placed from fl.to ft. Sand,silt,some clay,brown/hard 49 54
Surface Seal: E Yes ❑No To what depth? 18 ft. Sand,gravel,silt,brown/soft 54 95
Material used in seal Bentonite Granular Sand,gravel,silt,cemented,brown/soft,wb 95 113
Did any strata contain unusable water? ❑Yes O No Sand,gravel,more silt,some clay,brown/harder 113 117
Type of water? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name N/A Type:
H.P. Pump intake depth:_ft. Designed flow rate:_gpm
Water Levels: Land-surface elevation above mean sea level_ft.
Stick-up of top of well casing +1 ft.above ground surface
Static water level 88 ft.below top of well casing Date 9/25/2025
Artesian pressure_lbs.per square inch Date
Artesian water is controlled by (cap.valve,etc.)
Well Tests:
Was a pumping test performed? El No 0 Yes b by whom?
Yield gpm with_ft.drawdown after hrs.
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 well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test .
Bailer test gpm with ft.drawdown after_hrs.
Air test 13 gpm with stem set at 107 ft.for 1 hrs. Date 9/25/2025
Artesian flow gpm
Temperature of water "F Was a chemical analysis made? 0 Yes ❑ONo Start Date 9/25/2025 Completed Date 9/25/2025
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.
O Driller 0 Trainee 0 PE-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature ( '1-1?%•%,19L- 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 9/26/2025
ECY 050-1-20(Rev 11/18) 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 711 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
CHRYSALIS REAL ESTATE 10/21/2025
4530 NORTHEAST 29TH ST
SAMMAMISH, WA 98074
WELL SITE ADDRESS: 1301 NE TAHOYA RIVER RD, TAHUYA WA 98588
Pump Make & Model: 3/4 Pump Set At: 100'
Sounder Make & Model:
Make & Model: Measured in: GALLONS
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 14 146867 57'
1 14 146881 60'
2 13 146875 63'
3 13 146908 65'
4 13 146921 67'
5 14 146935 70'
6 12 146947 73'
7 12 146959 73'
8 13 146972 73'
9 12 146984 73'
10 12 146996 73'
15 12 147056 73'
20 12 147116 73'
25 12 147176 73'
30 12 147236 73'
35 12 147296 73'
40 12 147356 73'
45 12 147416 73'
50 12 147476 73'
RECOVERY
0 73'
1 71'
2 68'
3 65'
4 63'
5 61' 1
6 59'
7 57`
SIGNATURE
E NS P AND DRILLING
Pja.
'WARM D 36AA67 74:110,
axoal/Ir04 'COU O1MBATEmA ANALYSS,DRUB
.
Dale Sample col lea nine Sample Canty
Collected
JU 1 Zt 1 CI AM
12 :30 One I aSon'1
Yolk °ir Year
Type of Water System(check only one box) r�
0 Group A ❑Group B 0 Other v L
Group A end Group B Systems-Provide from Water Facilities Invent/(WFI):
IPN �r n 1
Ste:Chi ,{I < Aic� e 01.P toil
Confect Person:
Day Phone:(7i 0)'1 j1 ; Cal Phone:( )
Ems: Eve.Phone:( ) .
Send rtetite be frl name,ae6rasa and to code or wen)
b(A-ki.. -E gnyriS
I11 n2 �(A} 'I201-4. AvC—
Chc�Lla,A;t W r.. q0-31.
. .SAMPLEIPiiin AT{oN
Sample°olectsr by(name):
Specific location where sample co4lected: Special trrstructions or comments:
IlaI 1t1&QI1s,ya A'.i 1
'ia4w( c WA- °1f3S8a
14001: nN,rpys. tect«r!y one flPe ofearnpse tern types ltduoUgh 5 beivr)
1.❑Rooth*Dion Sample(111P) 2 0 Repeat Sample(AM)
Chbrinaiad:Yes No (tram dkVtulbnsytbm seer anal.mane)
Unsatisfactory routine lab number.
Chlorine Residual Tota(• _Free
3.0 round Water Rub Source Sample U ry routine Dolled date:
Is ! 1 • 1
Chlorinated:Yea4,_No
❑Triggered(AM Chlorine Residual Totel_Free__
❑Assessment(NP)
4. ell deco or OWi Raw Saute Water Sample(Enumeration) II 8
0 E.col ❑Fecal Mired Yoe,._
5.❑Sample Coasted Ix hdormdrar Oobr.
IAB USE ONLY DSRINKINt WATER RESULTS LAB:USED&Y
Q Urpattelecto rrTota'Conform Present and Salisfactory
❑Ecolpresent D Eel!absent
Bacterial Der>stty Resifts:Total Corlotrrt ii00mt Erol 1100rr.
Fecal C°gorm - 1100mL tiPC li at •
Replacement Sample Required: ❑TNTC Ci Semple too old
0 Sample Vobme O Damaged Container ❑
I Lab Ralwarce Kanter
D p5 IS:SO Qz3 ^ La
' Tir5 .L° a29--Q
Drea Repartee b oott Lab use Ony
5-d 28 316
OOHMarmun(eeea+adhr)•eraoeedeba ►+e rlevtwlareloi[aoratorU(roarltYd7�4
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
360-967-7010 VANGUARD .
cnrosAraxr
Nitrate/Nitrite
Analysis Report
Date Collected:(MM/DD/YY) System Group Type:(Circle one.) A B Other:
Water System ID Number _ System Name: (,14,, `le, j,sA fetalte- r.,(.rt rhvt
Lab Number/Sample Number. 2 a / 0 2 ._._ 6 County et-5Uv1
Sample Location t 3o I ft)C In.1,... y0. -ut.r DrZ lit_ Source Number(s) (List erl sources If blended or composited,)
-�a t 49O- (.va- RSsee L o Z 3 t s
Sample Purpose(check appropriate box) Date Received: (MM/DD/YY)
❑ RC—Routine/Compliance(Satisfies monitoring requirements) Date Analyzed: (MM/DD/YY) ,,..£12-_3/2-
Date Reported: (MM)OD/YY) 1 �?�?
❑ C—Confirmation(Confirrnatlon of chemical result)'
VI l—investigative(Does not satisfy monitoring requirements) COMMENTS:
❑ 0—Other(Specify—does not satisfy monitoring requirements) \) 2,5(0 e.5 - 16
Sample Composition(Check appropriate box.) Sample Type(Check one.) ❑Pre-treatment/Untreated(Raw)
0 S—Single Source 0 Post-treatment(Finished)
❑ B—Blended(List source numbers in'Source Numbers'field.) ❑Unknown or Other
❑ C—Composite(List source numbers in'Source Numbers`field.) Sample Collected by:(name) ,1e -•
❑ D—Distribution Sample Phone Number:
Send Report to: Bill to:(Client name.)
Moab— a, Srlv►A. AAA. 4t Ve h SvY14
iva2 IOW MA? Avg tktr2 ki4) -Ake— A .
(.lrtsiiiiy,.1:c lea. 16<3 Z aut.Irw & 5 i OA_ 96532
Analytical Results
Data
Exceeds MCL? Method/
DOH# Contaminant Qualifier , Results MRL SDRL Trigger MCL Units (X if Yes) IHaitich is
0020 Nitrate-N ND 0.5 0.5 _ 5.0 10.0 mg/L
206
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 if the contaminant amount exceeds the MCL under chapters 246-290 and 246-
291 WAC. If you have questions about this result,please contact the department's drinking water regional office in your area.
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 level.Systems with contaminants detected at concentrations at or above this level
may be required to take additional samples or monitor more frequently.
LAB COMMENTS
Revised December 2021