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Home My WebLink AboutWAT2025-00251 - WAT Application - 1/7/2025 i i i i WAT 2025 - 00251 r MASON COUNTY 415, 6thA Street 4...,„ Shelton,WA 98584 4 *:-:''jShelton:360-427-9670,Ext.400 Public Health & Human Services Belfair:360-275-4467,Ext.400 i 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. I 4. An approved building site plan must accompany this application. I ( Part 1: Applicant/ Parcel Identification t Name of Applicant: David Ravander Date: 8-12-25 ;i Mailing Address:4280 E.Mason Lake Dr.W.,Shelton,WA 98584 Phone: 360-355-5513 Parcel Number: 22233-50-00015ti 4 Type of Water System Reason for Application Public/Community Water System(2 or more 0 Building permit I connections) 2. P4'' /e // ❑ Division of land; 0 Individual water source(one connection), #of Parcels? SPL I� pc Well ❑ Boundary line adjustment 0 Spring/surface water Other(explain) ADU Permit BLD2025-01396 i ❑ Other(explain) ❑ Replacement or Remodel(please indicate name 1 If you have more than one residence connected of water system below if applicable—no 3: Y. to this well, check the Public/Community Water signature required) fr t System box. t= Part 2: Water Connection Information r ii Complete the section appropriate for the type of water connection being evaluated: l Public Water System VVEL2025-00110III Name of Water System: Z Po,— >' Je-ll Water Facility Inventory(WFI)Number: none (write"none"for wo-party)Ar I am the manager of this water system.The water system has been,3pproved for .2-- services.There ri are presently____I___connection(s)in use.This will be the Z`` connection. li 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 Ii, this change: k This water system is able and willing to provide water to this (these)connection(s)without exceeding the p limits of the water system or any limits set by state and local regulation. Print Name of Water System Manager v, a' j&va fri id- Phone 36 "35--r—SSi-1 Signature of Water System Manager �2"11,2744 Date O //y/Z 5- I d ( This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05108/2024 Page I of 2 ;} ii if F G , , Group B Water Systems i ❑ Satisfactory bacteriological test within last year(attach to application). i Individual Water Well lid Water well report(attached to application). Depth 96 ft. 3/19/2018 pl Well capacity Test(attached to application) 13 to 27 Pm 800 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 7 by a licensed contractor. Satisfactory bacteriological test within last year(attach to application). Vanguard Lab 8/25/2025 't l j Individual Spring/Surface Water i ❑ WDOE permit(attach to application) ii- u ❑ 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. 4 i Author of Statement Date Relationship to Applicant • o K it Part 3: Mason County Community Services Evaluation (staff use only) il ii XSatisfactory Determination: ti 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: z Applicant's water supply does not appear adequate to meet the needs of its intended use for the following t reason(s). If z EH APPROVED Reviewer's Signatures: Environ. Health: .Anderson 01/07/2026 Date 01/07/2025 4 This form may be scanned and available for public view at www.masoncountywa.gov ll Page 2 of 2 ° } + S I 1 of 1 ') u'' Q e ... , t r ,: :_: ::.E WATER WELL REPORT CURRENT °"r Original&I"copy-Ecology,2^`wrpy-wrier,3"t copy-driller Notice of Mien!Nit.-WYl';27 UU a'� crrxrrucuror ECOLOGY Construction/Decommission(".v"in click) Unique Ecology Well ID Tag No, BERMS fr.rAY.•,,,tCva, L C:o1151flICti01t Water Right 1'rnnil No. ❑ Decommission on/Gm/AL IjVS'1'ilhb977ChN P/olicc of Llfr u1 NumberProperly Uwi er Name Park!Ravan..ilcr z a PROPOSED USE] R1 Daintstic D leI tirinl ❑ Municipal Well Street Mhos 428D E Mason Lttl(r Drive W 0 UalVoler 0 lrrilolicm 0 Test Well ❑ Oil,rr city (.rapeviely County_AIM o11 r,1 TYI'EOFWORK: Uwtxr'stnanL•crofwcll(ifuronc than ane)_ Lvutlf3)n 11Clld-i14.ye lid Sec 33 Two 22N R 2W 1sW11 C n New well it Reconditioned Alerlxr,l:O Ling ❑ nom! O Ur6en (s,t,r Stilt REQUIRED) Or O Deepened ❑ Cable i�} notary 0 retied WWM undies,milled 98 it. DIMENSIONS: Dimmer af‘sell 1411/l.ong Mirth afccen)dctcrl well s+ O. — Lal Deg .A.7___ tot htitlfScc 20e�7.Gd N CONSTRUCTI0NMITAIL3 Long Deg 122 Longhli&Sec 56'51.1W' Caen [i8 %vclded (r " Worn,from +1 fl,in 93 11, --�' Tux parcel No,(Required) 22233541)0015 hooka, El Linn innalkd " Monk from a.to II O Threaded " !)runt tram 0.to tl. �-_ t, -_ Perfnrnrinns, l0 Ycs tell No CONSTRUCTION OR DI?COAIMISSION'PROCEDURE '1 ypr ofperfuratur uscrl _ Fortnntion:Describe by color,character,sire of material and siruclute ri and the kind and nature of the material in each strattlnt penetrated,wit 517Ji afprrfs in.by in.nn3 n:,,ofpcafa front It to It. Ictut une entry for each charge of information. (USE ADDITIONAL c, Scrims: klij Yrs ❑ No O IGPra Laotian 91 SIIEI TS If'..NECESSARY.} Monufrcturcr s Mow trliol'Machine Works _r__ MATERIAL I ROM '1'O '1)ye Sloped ninal No.___ _,_,.,.,.:A Brown gravelly line to medium sand,__,_ 0 t)ia,n Slut size km il.to 11. loose,dry : giant 5" SIst sire AIR Erato_01 11.in 97 fl. — __Browj gravOly line sand,sill bound, 8 _ Graselrt•'itrer packed: ❑ Yes 1l No Sircafgravelroorl light,dry 2 Materials placed tiara ft_to ft. Brown gravelly medium sandk{ight,wet 31 d Surfnco Sent:® Yes O No 'To whu tle{rlb4 4a il. Brawn gravelly fine silty sand,rig it t11„r 4_ 7 I Material toed in teal m.6'au.r:b1a, Brown gravelly fine sand,tight,wet 75 Did Any Karat carrni',nnrsxtbi miter? O Yet 17 No Brown medium sandy gravel,loose,water 88S This nrwntef) ncptlr of grata _wyfir0IVII gravelly flue silt,light,wet 9R , —M� —�YY4y�y Meihoil of staling strata offk PUMP: Mnuul'aettuc,'s Name -------„-----_---- }7jpr: 11.P. It l ti Ff I- 4 , ii ® _. _ _ .� _— __-_ __ fa Arcadia Drilling Inc. P.O.Box 1790 Shelton,WA.98584 Customer:Dave Ravander Well Tag#: BKR015 Phone:360-355.5513 Depth: 97' Well Site Address:4280 E Mason Lake Dr W,Grapeview Pump Set: 80' Date of Test: 3/2712018 Static: 21.2' TIME GPM LEVEL RECOVERY 1 Min 13 24.5 TIME LEVEL 2 Min 13 25.1 _ 1 Min 22.8 3 Min 13 25.25 2 Min 21.6 4 Min 13 25.25 3 Min 5 Min 13 25.3 4 Min 6 Min 13 25.3 5 Min 7 Min 13 25.35 8 Min 13 25.35 9 Min 13 25.4 10 Min 17.5 25.4 I' 15 Min 17.5 27 20 Min 17.5 27.09 25 Min 17.5 27.1 30 Min 17.5 27.15 35 Min 27 27.15 40 Min 27 31.1 45 Min 27 31 50 Min 27 31 55 Min 27 31 1 Hr 27 31 Ij is Ij Iie