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Home My WebLink AboutWAT52026-00007 - WAT Application - 2/3/2026 WAT 2026-00007 MASON COUNTY 6 415 N. 'h Street Shelton,N. WA 98584 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 2/3/26 Name of Applicant: Nolan Bentz Date: Mailing Address: 2701 140th Ave SW Tenino,WA 98589 Phone: 509-999-2475 Parcel Number: 32120-75-00070 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more l Building permit BLD2025-01394 connections) O Division of land: (Main residence) IRJ Individual water source(one connection), #of Parcels? SPL fi_cl Well O Boundary line adjustment ❑ Spring/surface water O Other(explain) O Other(explain) O 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) 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. 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 Phone Signature of Water System Manager Date 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 ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well l Water well report(attached to application). Depth 100 ft. El Well capacity Test(attached to application) 11.5-13 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. El 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) ® 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). cZAN °S Reviewer's Signatures: Environ. Health: Date 2/3/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 rMNIM1v Start Card No W101347 WATER W E L :.. R E P O R '" :Well I 9 AEC960 'pique STATE OF WASHINGTON Water Right P rmit No. Ii' OWNER: Name ADAMS, LAUREN Address PO BOX 1047 BELFAIR, WA 98528- _--_ 2) 35 = =-___......._.___ 110DLOCATION OF WELL County - NE 1/4 Nw 1/4 Sec 20 T 21N N., R 3W wM )tai STREET ADDRESS OF WELL for nearest address) PIN®AROSA YROAD, UNION O U—Lnd 7y��/� Q z ==__eC====s- = = (11 PROPOSED USE: DOMESTIC ! (10) WELL LOG 1�[ L6 sar X41 TYPE OF WORK: _ = . Owner's Number of wel, Formation: Describe by color, characte , size of material (If more rhan one) and structure, and show thickness of a ifers and the kind NEW WELL Method: ROTARY and nature of the material in each str tum penetrated, with _____= ..=.>________.. at least one entry for each change in ormation. (5) DIMENSIONS: Diameter of well 6 inches O Drilled 101 ft. Depth of completed well 100 ft. ; MATERIAL 0 17 FROM TO c« -------------------=== ._._______.__.= PACKED COURSE SAND GRAVEL PACKED GRAVEL COURSE SAND BROWN CLAY 17 51 !6) CONSTRUCTION DETAILS: 51 � 78 Casing installed: 6 " Dia. from +1 ft. to 100.8 ft. BROWN COURSE SAND GRAVEL 78 78 WELDED CASING " Dia. from ft. to ft. WET COURSE SAND SOME GRAVEL 71 911 " Dia. from ft. to ft. BROWN COURSE SAND GRAVEL C WATER Perforations: NO - . Type of perforator used ili NMEIV112D SIZE of perforations in. by in. perforations from ft. to ft. perforations from ft. to ft. JUL L 2� lI. perforations 'from ft. to ft. u I Screens: NO Manufacturer's Name HEALTH SERVICE Model No. Type Diam. slot size from ft. to ft. iQ Diam. slot size from ft. to ft. ) v Gravel packed: NO Size of gravel _. 3 rr, p Gravel placed from ft. to ft. • Surface seal: YES To what depth? 20 ft. co Material used in seal BENTONITE Did any strata contain unusable water? NO _ Type of water? Depth of strata ft. .. . Method of sealing strata off r•,_t '71 PUMP: Manufacturer's Name Type H.P. _ :8) WATER LEVELS: = Land-surface elevation above mean sea level ... ft. (10 0 a/O O Static level 70 ft. below top of well Date 05/26/98 e,�p Artesian Pressure lbs. per square inch Date Artesian water controlled by Work started 05/26/98 Com eted 05/26/98 = '9) WELL TESTS: Drawdown is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION: static level. I constructed and/or accept respon 'bility for con- Was a pump test made? NO If yes, by whom? struction of this well, and its co fiance with all Yield: gal./min With ft. drawdown after hrs. Washington well construction stand ds. Materials used and the information reported above re true to my best knowledge and belief. Recovery data • Time Water Level Time Water Level Time Water Level NAME ARCADIA DRILLING INC. Person, firw, or corporation) ( e or print) ADDRESS $6 17 PALZ Date of test / / Bailer test gal/min. ft. drawdown after hrs. [SIGNED) Lic se No. 2053 Air test 40 gal/min. w/ stem set at 95 ft. for 1 hrs. Artesian flow g.p.m. Date Contractor's Temperature of water Was a chemical analysis made? NO Registration No. ARCADDIO98E1 = ate 05/26/98 ..._ _ r 'Sod A . Printed from Mason County M Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Nolan Bentz Well Tag#: AEC960 Site Address: 490 E Pinedirosa Rd, Union Depth: 100' Date of Test: 1/22/26 Static: 78.3' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 11.5 79.8 TIME LEVEL 2 Min 11.5 80 1 Min 78.8 3 Min 11.5 80.2 2 Min 78.4 4 Min 11.5 80 3 Min 78.3 5 Min 11.5 79.8 6 Min 11.5 79.8 7 Min 11.5 79.8 8 Min 11.5 79.8 9 Min 11.5 79.8 10 Min 11.5 79.8 15 Min 11.5 79.8 20 Min 11.5 79.8 25 Min 13 79.8 30 Min 13 79.9 35 Min 13 79.9 40 Min 13 79.9 45 Min 13 79.9 50 Min 13 79.9 55 Min 13 80 1 Hr 13 80 Total Gallons Pumped: 807.5 Gallons Vanguard Laboratory a 2635 Parkmont Lane SW • .410 Olympia,WA 98502 •Q 360.967.7010 VANG AD Report of Laboratory Analysis LABORATORY Collected by: Ackley Pump Service Matrix Drinking Water 360-508-6393 Laboratory ID: V250923-10 Sampling Address: Date Sampled: 9/23/25 13:15 18308 Old Hwy 99 SW Date Received: 9/1/35 14:30 Rochester,WA 98579 Date Reported: 9/25/2025 Sample ID: 18308 Old Hwy 99 SW Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V250923-10 Analyst:CB Coliform,Total Negative 1 1 MPN/100 mL 1 9/23/25 18:12 E.coli Negative 1 1 MPN/100 mL 1 9/23/25 18:12 Nitrate by Hach Method 10206 Batch ID:V250923-10 Analyst:CB Nitrate(as N) ND 0.50 10.00 mg/L 1 9/23/25 17:09 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 09/25/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 09/25/2025 DF:Dilution Factor tT 17025:2017 MCL:Maximum Contaminant Level ACCBEIIrrEII .x►, t.AwtretroRv Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com 1 of 1