HomeMy WebLinkAboutWAT2025-00230 - WAT Application - 11/5/2025 j-LWAT 2025-00-230 .
i
4/4. MASON 'COtINTY 415 N.6'"Street
Shelton,WA 98584
Shelton:360427-9670,Ext.4t?0
Public Health & Human Services Belfair:360-27541467,Ext.400
Application for Determination of Water Adequacy
Instructions _
17C Complete Part 1. Fo determination'Ow be made until Part 1 is fully completed.
2. Complete only the portion of halt 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 aF pplication.
Part 1: Applicant] Parcel Identification
Name of Applicant � 6. f ru'4 Date: - IL-'05 '-ZD
i
Mailing Address: zj.j3 be ci.,- Phone: _._ 4O-2.1 t.4-l2 u3
Parcel Number: 1,7_5 "5-b-O03 . _ _ _
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit
connections) Division of land:
i individual water source tone connection), #of Parcels? SPL_
❑ Well Boundary line adjustment
C Springksurface water C Other(explain)
Other(explain) L Replacement or Remodel(please indicate name
If you have more then one residence connected of water system below if applicable- no
to this well, check the PubtMfCommunity Water signature required)
System box.
Part 2: Water Connection Information Two party well
WEL2021-00021
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: CcioG orrit,l_C'f 5i '1
Water Facility Inventory(WFI) Number: 14QN _v (write"none"for two-party)
Yj 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 2/46 connection.
El 1 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.
4r,
Print Name of Water System Mena = ' r' Air t - Phone I ) 3y9 a�
Signature of Water System U: `"___ Date 1+J5/26 Z.S ---
This form m -..'=' ..-ned and available for public view at www.masoncountywa4ov_
JAE1-1 ForrailDnoking Water Revised 0510V2024 Pone 1
Group B Water Systems
ySatisfactory bacteriological test within last year(attach to application).
Individual Water Well
181 Water well report(attached to application). Depth_ 262 ft.
Well capacity Test(attached to application) 12.5 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.
X 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.
• Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
�SL Reviewer's Signatures:
Environ. Health: Date 11/25/25
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
m
. 41WATER WELL REPORT CURRENT
Original h l'copy-t coloy7,2"copy owner,3"'copy driller Notice of Intent No.WE24755 -
aar.ar•+ar.r or Unique Ecology Well It)Tag NO.>I fM
ECOLOGY Construction/Decommission("x" in circle)
► 924
v4 Construction Water Right Permit No._ -
—
❑ Decommission ORIGINAL INSTALLATION r ,ty Owner Name Tile Lincolnow Notice one
—
Intent Number 'i
n PROPOSED USE: 0 Domestic 0 Industrial O Municipal Well Street Address 700 NE Have*Lake Dr.
II 0 DsWater 0 Irrigation ❑ Test well 0 Other City Tahuya County Mason
te TYPE.OF WORK: Owner'snumbs of well(if more than Oran) Location SW 1/4-1/4 U1/4 Sec 30 Twn�3 R 2 EWM Q174 Or
® New well ❑ Reounditioned Method.❑ Dug ❑ Bored 0 Driven (a,t,r Still REQUIRED) WOr
2 Cl Cabin ® Rotary 0 Jetted N
a Deepened
DIMENSIONS: Diameter of well 6 metiea,drilled 262 ft Litt/Long
th of con toed well 262 ft. Lat Deg Lat Min/See
Long Deg Long Mirt/Sec
CO^IS1RUCrfON t)ETAII.S
v ,
Casino el Weld 6
Welded Dian from:Li ft.to 252 ft. Tax parcel No.(Required)223305000333
Installed: 0 Liner installed .' Dim from ft to ft.
1 C Threaded " Darn.From ft.to ft.
ate. Perforations: C Yee ® Ne I CONSTRUCTION OR DECOMMISSION PROCEDURE
fe i Formation:Describe by color,character,sire of material and structure,
i Type of perforator used t and the kind and name of the material in each stratum penetrated,with at
i '� SIZE of perfs_,_in.by__,__in.and no.of pals—from_ft to -__fl. least one entry for each cfarige of information (USE ADDITIONAL
1SHEETS IF NECESSARY.)
t � ��: � Yes 0 No 0 K-Pan Location 255 — MATERIAL FROM TO
Manufacturer's Name Alloy Machine WQrs. Top soil 0 T
E Model No. 2 270 .
a Type Si inl s Brown till
a 5. Diam,1,Slot size 12 from 257 ft.to 262 ft_ L Gray till 170 230
! from ft.to ft.
Dian Slot eau 13rottn till i 230 245
ti Gravel/Filter packed: 0 Yes 0 No Size of gravellsand 2450 262
"� Sand&gravel with water
.n Materials placed from R to ft.
Surface Seal: ® Yes 0 No To what depth?ISft.
Material used in seal 13etonite
Did my strata contain unusal t water? 0 Yes 0 No Type of water, Depth of strata _
14.3
Method of scaling strata off.�,,,..,,,,, -- ------
}�' PUMP: irtatufaerwcr'sNameCarpadfoss
Type:SUb, N.P. 1112
WATER LEVELS: Land-surface elevation above man sea level ft.
1 7level DI Q ft.below top of wcil Date
1. CI
i. b Artesian pressure lbs.per square inch Date _
•
_ ( .valve.ac.}
13� Mexiari water is controlled by
5ta WELL TESTS: Drawdown is amount vista level is lowered below static kvel
Was a prop test made* 0 Yes 0 No If yes,by whom?
Mg Yield:__gat.hnin.with ft.drswdown after hrs. _.-----
) Yield gal/min with ft.drawdowa after Mrs P j
P Yield: _jallmi'.with. _ft.drawdown after his it t
st+ ter/rva!measured from
/� M.rnver/'Jwa(rw,t redden.as zory vlran rump turned off)(wok, 71
t..
+a Ij well trap ro wa er ItrrIJ '!
3 Time Water Level rime Water Level Time Water Level i 1� ` .
A state o ksvSul
Date of tat
Baiter test 11 gallmin.with 1 n.drawdow'n after 1 hissal . 1
re_� Airiest galimin.with stem se:at ft for his. -
�! Artesian flow g.p.m. Date
stes
Was a chemical analysis made? ❑ Yes ® Ne Start Bale 8f lO/I6 Completed Dote 8/18/16
Teagx+atureofvr+tet
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept respcnstbility for construction of this well,and its compliance with all Washington well
4' construction standards. Materials used and the information reported above are true to my best knowledge and belief. _
CIa t Pith Drilling Company Davis Drilling
,:, Driller a Engineer❑Trainee N ) 7 Address 340 NE Davis Farm Rd.
-Driller/Engcteer/Trauncc Signature t WA, 98528
City,State,Zip Belfair
t� Buller or trainee License No.2316 Contractor's -
r� IF EE:Drii cr's License N• Rani n N [late 2016
"` 1•i . of is iRf! ` IECotoR7►Wait?RrxdureeaFrraBrsm
F .. tr 0:,• ,i r #tact, ltttfailik,,� s i n ft Irm tt for OF
fi 'i . .' 't ,;,4.% i I a a,» *�fl' f nRloll Rtrielftvice at 711. Perso `spree ' Sabuity may tell TTY at 877-833-6341.
Printed fitting Mason County OMS
• 'David Wang & fwnpa
340 Ifli Vavi s farm Id
'fair,`Wa 98528
(360)801-6107
Project
Capacity Test TAG: BJM924
Date 3/17/2021
Pump 1 1 HP
Well Depth 262
Static Water Level 200.5
Draw Down Recovery
Time Water Level GPM 0 201.5
0 min 200,5 0 1 min 200.5 .
5min 201.2 12.5
10 min 201.4 12.5
15 min 201.4 12.5
30 min 201.4 12.5
1 hr 201.4 12.5
2 hr 201.4 12.5
3 hr 201.4 12.5
4 hr 201.4 12.5
1
is
1 r Pli-IltdatarklifdP
% UPEQMOfl C
Printed from Mason County OMS
26276 Twelve
Trees Ln NW
Ste.0 SPECTRA Laboratories-Kitsap
Poulsbo,WA 98370 ...Where experience emner:
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
"
Collected ,M
! Z�Math Del Year 1:( i K Y'�4 bUn
Type of Water System(check only one box)
0 Group A 0 Group B
Group A and Group B SSysstemsy—Provide from Water FacilitiessIInnv-entory(WFI):
ID# bk ILQJ✓ CiQsL\c, VA.' V'A mes
l.�
System Name: 100 N1 L� �{� Dr
Contact Person: V v ii
Day Phone Cell Phone:
Email: Eve.Phone:
Send restdts to:(Print full name,adimpitieWerettreuledronlo copy of mutts)
PO 80X 123
PORT ORCHARD WA 98366
C1:HIr TON ul[Wr, <•]it t 1►pnstufaa�CCllA
SAMPLE INFORMATION
Sample collected by(name): eC
Specific location where sample collected: i Special instructions or comments:
Rom Ib
Type of Sample(check only one box)
1.❑Roudne Distribution Sample(AlP) 2.❑Repeat Sample(AIP)
Chlorinated:Yes ❑ No❑ (/turn distribution system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample
S I I Unsatisfactory routine collect date:
I 1_
Chlorinated:Yes No
❑Triggered (AR) Chlorine Residual:Total Free_
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) IS I I
❑e}}}���E.croli catered Yea_No
15.I Sampie Collected for Information Only: r .
LAB USE ONLY DRINKING WAT R RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and I V)Satisfactory
❑E.coli present ❑E.coliabsent
Bacterial Density Results:Total Coliform mpn1100m1.E.colimpn/100m1.
Fecal Coliform ctu/100m1.
Replacement Sample Required: ❑TNTC ❑Sample too old
0 Sample Volume ❑Damaged Container ❑
me R ived Lab Reference Number
Recap%Temp C':\_`� -1 Method C n lsaxT-COUNT/sm9222D
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