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Home My WebLink AboutWAT2025-00134 - WAT Application - 11/21/2025 • WAT 2025-00-134 MASON COUNTY 415 N.6th Street Shelton,WA 98584 J d 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: PINNACLE CONSTRUCTION NW LLC Date: 11/21/2025 Mailing Address: t 10 W"K"STREET SHELTON.WA 98584 Phone: 360-780-3890 Parcel Number: 220072250020 4 Type of Water System Reason for Application NI Public/Community Water System (2 or more ® Building permit BLD2025-00704 connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ 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. Two Party Part 2: Water Connection Information WEL2025-00099 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) O 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. ❑ 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 Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.gov J I Forms`,Drinking Water Revised 05/08/2024 Page 1 of Group B Water Systems ❑ Satisfactory bacteriological test within last year (attach to application). Individual Water Well ® Water well report (attached to application). Depth 84 ft. l Well capacity Test (attached to application) 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 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. I 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: c l(kOV\16(. - 11/21/25 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Pace 2 of -- -7 DEPART AIENI OI NaueoftntemNo WE59900 WATER WELL REPORT ECOLOGY Unique Geology Well ID Tag No. BQC169 Type of Work: Stare of Washington Site Well Name(if more than one well): ❑+ Coasmxtiisa 9 Domineeission Original installation Not No. Water Right Permit/Certificate No Proposed Use: O Dais tic 0 tatusrrul 0 Municipal Property Owner Name Mel Enoer 0 pswuairp 0 irrigation 0 Test Well 0 Other Well Street Address 1 170 E Bertelsen Rd • Cma Novwell Type: MAW: City Shelton County MOOD well 0 Alteration 0 Driven 0 kind ❑Cable Tool ❑tag 0 Other ❑Dug ®Air- 0 Mlle-Rotery Tax Parcel No 22007-22-50020 Dimensions: Diameter or bones 6 in,to 85 a. Was a variance approved for this well.' ❑Yes Da No Depth ofcompleted well 84 a. ' If yes,what was the variance foe' Coc a-nett®a Details: Wait Casing Leer Diameter from To Thickness Steel PVC Welded Threadjil 0 WWM a❑EWM i G g in o 7_,1_, .26 in 3I 0 PI 0 Location(see instructions on page 2) Cl I ❑ in _- — _in ❑ I 0 ❑ 1 ❑ NW ''Vein of the NW 54;Section 2 Township 20N Range 2W ❑ 1 ❑ __in ❑ 1 ❑ ❑ 1 ❑❑ 1 0 in in. ❑ I ❑ ❑ I ❑ Latitude(Example:41.12345)47.24130 N Longitude(Example;-120.12345) - 122.98745 W Perforations: O Yes O No Type of perforator used Driller's I.oRlCoostrrctton or Detoaamiulon Procedure No.ofperfauioro_ Sim of perforations_in by_at Formation:Describe by rotor,ekweter.cite of notarial tinsel atriecae,and the kind and Perforated fruit] ft.to a below ground surface 'more of the®fast Meech byte per,wish at last one may for eat:cimoge of SeIll K-Packer Depth 18 a information. Use adMoial skeins if aecaasary. M nufar re Yes ❑Aso Material From To tvbtaifactiii,a'i Name Alloy Machine Works 0 29 Type Staktless sIoU d Model No. Brown sand,gravel,slit Diameter 5_ Slot sire At4 in from 73 ft to 78 R Brown sand.gravel,silty clay 29 52 Diameter S Slot sire 000 is from -.Fs__it to s. 52 61 Brown sand,gravel.wet Sajsd/Fi1 Ur tack:C7 Yes Ill No Size of pock material,in Brown silt.sand and gravel,water 61 70 ktataials pied from ft.to—it Brown sand,gravel,water 70 78 siaiaee Sat: fl Yes O No To what depth' 72 tt Brown sand,tight,less water 78 84 Material toed a seat Bentonite chips Brown clay 84 85 Did sly strata cootam unusable wise(' ❑Yes I)No Type of waits? Depth annul Method deeding Beata off Pump: Macnfatirrer'U Name Type. H P._ Pump Mudge demi: ft. Desiped Sow rare:__rpm Water t.evets: toad-surface ekvalioe above taw sea level 256 ft. Stick-up of top of wall eating.1.5 t above Found surface Static water level 35 B.below top of well casing Date 7/9125 Artesian pressure—lbs.per square inch Date Artesian water is controlled by (cap,valve,tie.) - Wel Tests: Was a pumping test performed?PI No C7 Yes L-> by whom'? Yield Wm with_it(tamrowe after_hem Yield__grim with R.drawdoan sae,_____sus. Yield ;pea with t drewdown mitt_hrs , Recovery data(lime-zero when pomp is'earned our-water keel messaged From well top to wate keel) Wyci Level Time WWa Level Time Water Lewel Time Date of pinnpuig test Haiku ten__Wm with—t Mawdown alter bet Au tan 10 spat with Bien sa al 60 B for 1.5 his j- Oak 7/9/25 Artesian Bow__gpm Temperature of water 50 •f Was a chemical a elysis made' O Yes 18 No Start Date 7/9/25 Completed Date 7/9/25 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 0 Driller 0 Tra. -Pin a James Johnson DrdlingCompatry Arcadia Drilling Inc. Signature Address PO Box 1790 --L License . 3479T City,State,Zip Shelton,WA 98584 IF TRAINEE.Sponsor's License No,2874 Contractor's /f� Regisustion No.ARCAD01098K1 Date 7/9/25Sponsor's Signature f OSO•I.20{Rev 09/1 S) if you r4".dus doctvneni In an +m alntrfte formal.please call the Water Resources Program at 360-r07.6872. Primed rot p60yppgwfkktiodr3 k a ton"calU2l I for Washington& lay Service. Persons with a speech disability can call877.433-6341. Printed from Mason County OM° 44.111111110.1111.11111100.101111111 Arcadia Drilling Inc. P.O.Box 1790 Shelton,WA.98584 Customer: Mel Enger Weil Tag#: BQC169 Site Address: 1170 E Bertelsen Rd,Shelton Depth:84' Date of Test:7/22125 Static: 35.6' Pump Set: 60' TIME GPM LEVEL RECOVERY 1 Min 6.5 38.8 I TIME LEVEL 2 Min 6.5 41 - 1 Min 47.8 3 Min 6.5 42.2 2 Min 43.2 4 Min 6.5 43.1 3 Min 41.8 5 Min 8.8 43.6 rl 4 Min 39.6 6 Min 8.8 45.6 I_ 5 Min 38 Ii 7 Min 8.8 46.5 16 Min 37.3 !. 8 Min 8.8 47.3 ( 7 Min 37.7 9 Min 8.8 47.8 I 8 Min 37.5 10 Min 11 48.1 9 Min 37.2 r: 15 Min 11 52.2 10 Min 37.1 ' ' 20 Min 11 53.1 25 Min 11 53.5 30 Min 11 53.65 35 Min 11 53.9 40 Min 11 53.95 45 Min 11 54 50 Min 11 54.05 55 Min 11 54.1 1 1 Hr 11 54.1 1 Hr 10 Min 11 _ 54.25 I IPrinted From Mason County DMS Printed from Mason County DMS Vanguard Laboratory • 2635 Parkmont Lane SW,Suite A Olympia WA 98502 VWRA•D 360-967-7010 COUFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Semple County Cdaelea Mason 07/22/2025 4 , t1' 1.47 a ow Year Type of Water System(check only one box) ❑Group A ❑Group B ■Oe Group A and Group B Systems-Provide from Water Facilities Inventory(WF I) System Nam. Mel Enger Costal Person:Arcadia Oiling,Inc Day Phone:(360 )426-3395 1 Cal Phone:( ) Email. Eve.Phone:( ) Send resin a(Prue fie name,accrete aid rip code or sued) • anneeercediwareawcorn ANO jennelewassadranecons SAMPLE INFORMATION sa"1p1e"wed bYlne"18):1170E Bertelsen Rd SpeciEc loodiai where sample collected. Special itstruli ns a,,ornments BQC1S9•1170 E Berteresen Rd.Shelton Type of Sample(sated only one type of sample from types I lwough 5 belpre) C 1 0 Routine Distribution Sample OP) 2.0 Repeat Suggs WP) Chbnnated Yes No Morn 6stnt„eon system aver uruat.towns) Unsatisfactory routine lab number Chlorine Residual Total Free__ 3 Ground Water Rule Source Sample Uruatlsfactory routine collect date S 11 i Chlorinated Yes_No___ ❑Tnggered(AiP) Chlonne Residual:Total_ Free ❑Assessment (AP) 4 Surface or QWI Ran Source Water Semple(Enumerebcn) S I ❑E.col ❑Fecal Farea.e. N� 5.®Sampie Colecad ar Infamaaon only: —� LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coition Present and 1E Satisfactory ❑E cot present ❑Erne absent Bacterial Density Results Total Conform /1(10rN. E.coe /10Dns Fecal Cckfu m r100m1. HPC f1 rrtt Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0 Caubildre 11D Rerrerce Wirt Remo�� 5 It 0-.00 va5til -aa Re Term • Mood Code: SnrA22.2,') Deis Resoled to 00+1 Lab Use Orgy Dor,Lao-Samosa (,j� From 285- 2322 VVV Mason wmr.bow ara i R Mt"1, 1"of't Printed from Mason County OMS "6"l'•wr••e.•4":"."*"