HomeMy WebLinkAboutWAT2025-00241 - WAT - 2/6/2026 / . WAT ZCZ5 - cozy/
MASON COUNTY
1 COMMUNITY SERVICES
w/ Building,Planning,Environmental Health,Community Health
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy FFB 0
Instructions R u 2020
1. Complete Part 1. No determination can be made until Part 1 is fully completed. 671/FO
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: Jason Campbell (Applicant) Date: 11-19-25
Mailing Address: 406 108th St S Tacoma WA P8444 Phone: 564 546-0742
Parcel Number: 223097690151
Type of Water System Reason for Application
Public/Community Water System (2 or more [ Building permit 1101075 Q/33(
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
❑ Spring/surface water O Other(explain)
❑ Other(explain) 2 party well
❑ 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 YV �/, Z O -0O�D1-�l
Name of Water System: iC ('o C_K l /
Water Facility Inventory(WFI) Number: None
(write"none"for two-party)
321. I am the manager of this water system. The water system has been approved for a services.
There are presently a connection(s) in use. This will be the oltr.d 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. (�
Signature of Water System Manager 1li J r, +'` � Date V / (/L(4;
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well //y
E'' Water well report(attached to application). Depth 13 T ft. D' 1 r 7O
Well capacity Test(attached to application) G 1I ?0(eie:' gpm ? `100 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). 1O(Zot'‘'
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/blannino 14_15_16_22_
Water use or limitation recorded N/A Yes
Well Drilled ............... Date
Individual Spring/Surface Water
O 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:
/kr
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-De ermination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements m Chapter
36.70A Pi"?
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the fol owing 0 lip
pt
reason(s). 4f4S0N " FB O
ca0 9 20
Reviewer's Signatures: �'j' 4'j.' �6
Environ. Health: Date if 7 G MF4/Tg1.HF
,kTy
2 of t
CSD Director: Date
Origin FFile Department
end clog Copy with WATER WELL REPORT Start Card No 064489
Departt of Ecology
Second Copy—Owner's Copy STATE OF WASHINGTON
Third Copy—Drillers Copy Water Right Permit No
0 (1) OWNER: Name Todd Apting Addeo' NE 111 Bedrock Rd Tahuya WA 98588
0 (2) LOCATION OF WELL: County Mason . NE w SE tl sec 9 T 23 N.,R 2W W M
Ce (2a) STREET ADDDRESS Of WELL(or nearest address)
mm
• (3) PROPOSED USE: LX Domestic Industrial C] Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
O Irrigation
O Dowels( Test Will ❑ Other O Familiar Describe by color, charade., Noe of material and structure. end show
U/) Ihidtneu of aquifers and the kind end nature of the material in each stratum penetrated,
(4) TYPE OF WORK: Owner's nlmtber Of well weft al least one entry for each change of Information.
(H more than one) MATERIAL FAOet TO
C Abandoned L. New well IX Method: Dug L7 Bored ❑ — -- - . --..--_—..•.—. ._ -- -_
O Deepened Ii Cable X3 Driven L7 _
Reconditioned ❑ Rotary t7 Jetted ❑
C Brown conglomorate 0 4
O (5) DIMENSIONS: •
•
zr. Diameter of well 6 inches-
14 Drilled 137 feel. Depth of completed well 137 ft. Hardpan 4 83
E (6) CONSTRUCTION DETAILS: ('a.,Pntarl sand & bras. 1 wi th dater .83 1 30
1° Casing Installed: 6 ' Diem.from 0 ft.to 132 --
tt. —
iii WetLiner!�taead® ' Diem.from ft.to n- Sand & gravel w1 th water - 130 ! 137
d Threaded O }' Diem from ft.to h.
iC
ear Perforations: Yes NoX J —
O Type of perforator used _
O SIZE of perforations in.by_ In.
C -- pertorettonehom It.to ft.
0 perforations from ft.to h.
- perforations from ft.,o ft.
ni
3 Screens: Yee® NoD
Manufacturer's Name Hous t oD — .........
S Type Stain1PSS Model No. (5
4.0 Diem. rj11 Slot ai:e 50 from 132 t.to 137 ft. :F = '-"J 0 --
- Diem. Slot size Irom ft.to n. l
C
Gravel packed: Yes No Li Size ofgravel • '
L. Crawl placed from ft.to ft. 3'
AS 1' r...
7j Surface pal: Yea® No❑ To what depth? 1 A ft.
1
l' Material used in seal BP ton i to -
ODel any strain contain wooed*wafer? Yes❑ No E -T_
Z Type of wester? Depth ofetreta �' —�-- - _.- ----.—
(1) Method of sealing strata oil ----- - --- - ..-
411
O (7) PUMP; Manufacturers Neme MyPrs
Type: sub. KR_VA
4
i
l
)14
CB (8) WATER LEVELS: lead-evrraa.Nwrloe
0
100 above mean ails lewt ft.
Static level ft below top of welt Date
0 Artesian pressure lbs.per square inch Oct. — _.___�__--_
Arteeren wale.is controlled by
W (Cep.valve.etc.)) 11f�
d Work started ,t9. Completed DeC. „g_..9.0
(9) WELL TESTS: DrawdOwn is am t water level is lowered below static level
4.1 Wes•pump test made?Yee❑ No IX.' ,r yea,by whom? WELL CONSTRUCTOR CERTIFICATION:
C Yield: gill.i min.with ft.drawdown after bre-
a) - I constructed and/or accept responsibility for construction of this well,
E - and its compliance with all Washington well construction stenderds.
Materials used and the info►metion reported above are true to my best
kw Recovery dale(lime taken es zero when pump turned off)(water level meesered knowledge end belief.
ITS from well top to water level)
O. Trine Wolof Lerei Two WerwLoyd TIr.. Wrier Level
d NAME Davis Drilling
CI (PERSON.FIRM.OR CORPORATION) (TYPE OR PRINT)
CD Address jelfair 98528
F" Date of test
..O(Signed License No. 1 AAfi
0a,lsrtest 16 gel.i min.with 7 ft.drewdown after.__.1.__hrs. (WELL DRILLER)
Convector's
Airtest gel./min.with stem set el ft for hit.
N �IlT1T�1()()A Date IIP_G_ f9_90
Artesian flow e.o.m. Del•_
Temperature of water_Was a chemical analysis mede? Yes❑ NO® (USE ADDITIONAL SHEETS IF NECESSARY)
ECY 050•i-20 (i0.e2) '329- ""3
Davis Drilling, Inc.
340 NE Davis Farm Rd
Belfair, WA 98528
275-5367
Test pump for:
Erik Haney
111 NE Bedrock Rd
January 20, 2020
Pump: 1 hp Depth:
Static Level: 105' Pump set:
Draw Down
Time Water Flow GPM
Level
0 min 105' 0
5 min 107.5' 13.5
10 min 107.4' 13.5
15 min 107.5' 13.5
30 min 107.5' 13.5
1 hr 107.4' 13.5
2 hr 107.5' 13.5
3 hr 107.5' 13.5
4 hr 107.5' 13.5
Recovery
Time Water Level
0 min 107.5'
1min 105.5'
2 min 105.3'
3 min 105.3'
4 min 105.2'
5 min 105.2'
10 min 105.1'
15 min 105'
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C0LIF0RM BACTERIA ANALYSIS
Nle Sans*,l'nllecled l inn Siwimhr County
I IC / 4 _ LAM I S a it "u
V1 -_ � >�.>a. JAN r+�
M,.+M pat ' ' —
1101t,
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TT('TT('nl Water System(check only one box) RPrIvele Household RECEIVED
❑Group A ❑Group B 0 Other_ --
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
System Name:
Contact Person: I ( s
Day Phone:( ) rl Cell Phone:(3(00) 2•Off- �i 1 G
E-maii•pr fl4 ctI f)y`)9Y*Oi I.Cory Eve.Phone:( )
S d results to:(Print full name,address andzip code or email address)
G [y.SS�g\ 4!',ev11a�� -----
lit VV4- Ig o[Ro
Gt) ► "1,w q S2
SAMPLE INFORMATION
Sample collected by(name):p-I` s� 1 , ., V.e v tO s t
Specific location or address where sample collected:V Special instructions or comments:
d of ss
Type of Sample(must check only one box of#1 through#4 listed below)
1. Routine Distribution Sample 2,Repeat Sample(after unsat.routine)
Chlorinated:Yes No 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli—GWR(NP)
❑Fecal—Surface.Owl,springs(numeration) Unsatisfactory routine lab number.
Filtered:Yes_No_
❑Assessment Monitoring(NP) Unsatisfactory routine collect date:
['Other
I I
S
4.0 Sample Collected for Information Only
Investigative_ Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY
0 Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent o Coliform detected
Replacement Sample Required:
0 Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code:51 SM 9223B ❑SM 9222D Dale and Time Received:et—lo 0
❑SM 9215B t� 0 Enterolert® _I l4- 2.i, ICS
Dale and lime Analyzed: (• I r(7__(e Dale Reported:l•(5-
Sample Number lOON nempe,plus fire digits)
D B 0 lab Use Only:
rote ran,fd)1J_b{mraed 1123)
Pt. Cason