HomeMy WebLinkAboutWAT2026-00024 - WAT Application - 3/19/2026 WAT 2026-x0024
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MASON COUNTY
COMMUNITY SERVICES
w "' Building,Planning,Environmental Health,Community Health
415 N 61"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
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 on Applicant: AMY BOND Date: 02/02/2026
Mailing Address: Phone:
Parcel Number: 220247890021
Type of Water System Reason for Application
O Public/Community Water System (2 or more IN Building permit BLD2026-00101
connections) ❑ Division of land:
X Individual water source (one connection), #of Parcels? SPL
X Well
O Boundary line adjustment
O Spring/surface water
❑ Other(explain)
❑ 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)
❑ 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\E1-1 Forms\Drinking Water Revised 1/25/2013
Individual Water Well
® Water well report(attached to application). Depth_ 246 ft.
Did Well capacity Test(attached to application) 11 gpm >400 qpd.
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.
►4 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 14_15_16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date
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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
3/19/26
Environ. Health: Date
CSD Director: Date 2 oft
WATER WELL REPORT t 5 1MIi DE ARTMENT OF Notice
of Intent
No.
WE61778
°' ECOLOGY Unique Ecology Well ID Tag No. BRL 671
Type of Work: .77.7" ''"'. Rata of washington
O Construction Site Well Name(if more titan one well):
❑ Decommission c==> Original installation NOf No. Water Right Permit/Certificate No.
Proposed Use: ID Domestic ❑Industrial 7 Municipal Property Owner Name Amy Bond
❑Dewalerina ❑Irrigation ❑'rest Well ❑Other
Well Street Address 801 E Jared Rd
Construction Type: Method:
❑New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City_Shelton County Mason _
❑Deepening ❑Other ❑Dug J Air- ❑Mud-Rotary Tax Parcel No. 22024-78-90021
Dimensions: Diameter of boring 6 __in.,to 246 ft.
Was a variance approved for this well? ❑Yes ❑No
Depth of completed well 246 ft,
if yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
6 _in. +2 241 .25 in. iJ I ❑ DIE Location(see instructions on page 2): G W WM or LI EWM
❑ I ❑ in. in. ❑ I ❑ ❑ C SE 1/4-',/,of the SW 5:,;Section 24 Township 20N Range 02
❑ I ❑ in. in. ❑ I ❑
❑ I ❑ in in ❑ 1 ❑ ❑ 1 r Latitude(Example:47.12345) 47.20113
Longitude(Example:-120.12345) -122.87867
Perforations: ❑Yes N No Type of perforator used
Drillers Log/Construction or Decommission Procedure
No.of perforations Size of perforations in.by in. Formation:Describe by color,character.size of material and structure,and the kind and
Perforated tiom ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one enhy for each change of
Screens: A Yes ❑No K-Packer ' > Depth 240 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type Stainless Stel Model No.
Diameter 5 in. Slot size .016 in.from 241 ft.to 246 ft. Top soil 0 1
Diameter in. Slot size in.from IL to ft. Sand,gravel,lots of silt,brown/soft 1 6
Sand,gravel,silt,brown/soft 6 51
Sand/Filter pack:0 Yes N No Size of pack material in.
Sand,silt,less gravel,brown/soft 51 64
Materials placed from ft.to ft.
Sand,coarse,some silt,some gravel,brown/soft 64 100
Surface Seal: Al Yes 0 No To what depth? 18 ft. Sand,silt,brown/hard 100 125
Material used in seal Bentonite Chips
Did any strata contain unusable water? ❑Yes No Sand,medium,little,silt,brown/soft 125 165
Type of water? Depth of strata_ Sand,medium,little silt,trace of water
brown/soft 165 191
Method of sealing strata off
Clay,silt,some gravel,brown/hard 191 200
Pump: Manufacturer's Name N/A Type: Sand,gravel,silt,medium gravel,some large
H.P. Pump intake depth: ft. Designed flow rate: gpm gravel,brown/soft 200 213
Water Levels: Land-surface elevation above mean sea level fl. Coarse sand,some gravel,silt,brown/soft
Stick-up of top of well casing +2 ft.above ground surface 213 224
Static water level 172 fl.below top of well casing Date 12/23/2025 wb
Sand,silt,clay,some gravel,brown/hard 224 233
Artesian pressure lbs.per square inch Date
Artesian water is controlled by leap,valve.etc.) Sand,silt,small gravel,brown/soft,wb 233 244
Sand,silt,some water,brown/soft 244 246
Well Tests: Clay,gray/hard 246 248
Was a pumping test performed? 0 No ❑Yes ' > by whom?
Yield spin with ft.drawdown after hrs.
Yield .....,_...__gpm with_ft.drawdown after hrs.
Yield gpm with it.drawdown after firs.
Recovery data(time rr,zero when pump is turned off—water level measured from well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test
Bailer test gpm with ft.drawdown atter hrs.
Air test 16 gpm with stem set at 245 ft.for 1 hrs. — Date 12/23/2025
Artesian flow gpm _
Temperature of water "F Was a chemical analysis made? 0 Yes E No Start Date 12/22/2025 Completed Date 12/23/2025
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
El Driller❑Trainee❑PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature Address 1162 NW State Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 12/24/2025
ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at
360-407-6872. Persons with hearing lass can call 711 fm-Washington Relay Service. Persons frith a speech disability can call
877-833-6341.
MOERKE & SONS PUMP & DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805
PUMP TEST
CLAYTON HOMES 12/30/2025
AMY BOND
WELL SITE ADDRESS: 801 EAST JARED RD, SHELTON 98584
Pump Make &Model: Pump Set At: 80'
Sounder Make & Model:
Make & Model: Measured in: GALLONS
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 0 153845 198' 400 GAL.TOTAL START
1 11 153856 200' W/D.D
2 12 153868 201.4'
3 14 153882 201.4'
4 8 153890 201.8'
5 12 153902 201.8'
6 11 153913 201.8'
7 11 153924 201.8'
8 12 153936 201.8'
9 11 153947 201.8'
10 11 153958 201.8'
15 11.4 154015 201.9'
20 11.2 154071 201.9'
25 11.2 154127 201.9'
30 11.4 154184 201.9'
35 154241 201.9'
40 154245 201.9' 400 GAL.TOTALIZATION
COMPLETE.RECOVERY
TO 0 GAL START WITHIN
30 SEC.
SIGNATURE:
MOERKE AND SONS PUMP AND DRILLING
Vanguard Laboratory
'
'235 Parkmont Lane SW,Suite 6 A
Olympia WA 98502
vf-MIMD 360-967-7010 '
GN021/F04 . ;CO,LIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
t2.. /36 / 2„T uY t,�(, y`{❑Am wd_ f�
Moth Day Year
Type of Water System(check only one box) (�,v
• O Group A O Group B f gOther \ +
. Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
_
IDS
System Name: e ut%.r t }„A ti ,IQs �.C.,
Contact Person: pt t,, b ,,.
�, . `, 44,0,,c,v444
Day Phone:T34e) 745 3785 Cell Phone:( )
Email: Eve.Phone:( )
Send results to:(Print full naie.a�sswanndd zip code or e•mait T'�
;.i SAMPLE INFORMATION
Sample collected by(name):
otit,Jr/
Specific location where sample collected: Special instructions or comments.
WA- celftA
Type of Sample(select only one type of sample from types 1 through 5 below) i
1.O Routine Distribution Sample(MP) .2.O Repeat Sample(NP)
(from distribution system after unsaL routine)
Chlorinated:Yes No
Unsatisfactory routine lab number:
Chlorine Residual:Total_Free
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
ISI I I / /
Chlorinated:Yes No
❑Triggered(NP) Chlorine Residual:Total _Free
❑Assessment(AN)
4. Surface or GWI Raw Source Water Sample(Enumeration) S I I
❑E.coil O Fecal Firmed Yes_No
5. ,Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS I.AB USE ONLY.
❑Unsatisfactory Total Coliform Present and I Satisfactory
0 E.coli present . ❑_Ecoli absent
Bacterial Density Results:Total Coliform /100m1. Ecoii /100ml.
Fecal Colifomr /100m1. HPC /1 ml.
Replacement Sample Required: O TNTC O Sample too old
❑ Sample Volume O Damaged Container O
Date/Time Receive�1: 3 t$b,Referexe Nu.81 t
,!C.f! Z VZs t2.��-
Receipt Temp C°: Method Code:
Date Reported to DOH tab Use Only:
DOH Lab-Sample#
205-n i
l t
DOH Fern 1111-310 73413einete/r7j•ere mini th,m 6caCror in an dsinerno fond,call 850.525.0127(To0iTTY w971 I)
This ear oinci Mfa5om cro rabble tannin dohaagodmiakinawaler.
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
t"ar;
Olympia WA 98502 ,7,
360-967-7010 ' r
LAflcSl4hTdStY
Nitrate/Nitrite
Analysis Report
System Group Type:(Circle one.) A B then
Date Collected:(MM/DD/YY) ���d� � Y yp '
Water System ID Number. System Name:Cd4"fieviA, UrcieteS ,�1G
Lab Number/Sample Number. 2_11_,5�12` ._1__1...1_ County: l)y1oeSOY.
Sample Location got E. 1,« �-0 Source Number(s) (List all sources if blended or composited.)
Sample Purpose(check appropriate box) Date Received: (MM/DD/Yl) J1 1. IW
RC—Routine/Compliance(Satisfies monitoring requirements.) Date Analyzed: (MM/DD/M') 1 2/3 2 .5....
❑ Date Reported: (MM/DD/Y) 0 1,/0 2 /2 6
C—Confirmation(Confirmation of chemical result)*
❑ I—Investigative(Does not satisfy monforingrequirements) COMMENT {
❑ O—Other(Specify—does not satisfy monitoring requirements) 11;5
Sample Composition(Check appropriate box) Sample Type(Check one.) 4Pre-treatment/Untreated (Raw)
5—Single Source ❑Post-treatment(Finished)
0 B--Blended(List source numbers in Source Numbers"field.) ❑Unknown o Other
0 C—Composite(List source numbers in Source Numbers"field.) Sample Collected by(name)
❑ D—Distribution Sample
Phone Number: I98 .41.t$
Send Report to: Bill to:(Client name.)‘04,1.t(.". a>r
1),"*.CS S vitr
Analytical Results
Data Exceeds MCL? Method/
DOH# Contaminant Qualifier Results MRL BURL Trigger MCL Units (X if Yes) Initials
0020 Nitrate-N 2.08 0.5 0.5 5.0 10.0 mg/L Hach 10206
NOTES
*Confirmation:Include the original lab number,sample number,and collection date of original sample in either comment section.
--No trigger value for combined nitrate plus nitrite.
Data Qualifier:A symbol or letter to denote additional information about the result. •
DOW:Department assigned contaminant number.
Exceeds MCL(Maximum Contaminant Level):Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-
291 WAC. If you have questions about this result,please contact the department's drinking water regional office in your area.
METHOD/INITIALS:Analytical method used/Initials of the analyst that performed the analysis.
mg/L:milligrams per liter or parts per million.
MRL(Method Reporting Limit):The lowest quantifiable concentration of a contaminant.
SDRL(State Detection Reporting Limit):The minimum reportable detection of a contaminant as established by the department.
Trigger:The department's drinking water response level.Systems with contaminants detected at concentrations at or above this level
may be required to take additional samples or monitor more frequently.
LAB COMMENTS
Revised December 2021
I