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Home My WebLink AboutWAT2026-00042 - WAT Application - 6/16/2026 WAT 2026 - 00042 MASON COUNTY 415 N.6th Street Shelton,WA 98584 c Shelton:360-427-9670,Ext.400 :e 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: UPSTATE ENGINEERING INC. Date: 02/05/2026 2T. TH \TIW 425-354-4105 Mailing Address: MOUNTLAKETERRACEWA98043 Phone. Parcel Number: 322134390162 Type of Water System Reason for Application O Public/Community Water System (2 or more NJ Building permit BLD2026-00137 connections) O Division of land: NI Individual water source(one connection), #of Parcels? SPL IN Well O Boundary line adjustment O Spring/surface water O 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. 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 • Water well report(attached to application). Depth 249 ft. 01/02/2026 ® Well capacity Test (attached to application) 12 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. 01/02/2026 ® Satisfactory bacteriological test within last year(attach to application). 01/09/2026 Individual Spring/Surface Water O WDOE permit(attach to application) O 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. Author of Statement Date Relationship to Applicant • • Part 3: Mason County Community Services Evaluation (staff use only) IX 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). EH APPROVED Reviewer's Signatures: Environ. Health: Anderson 03116!?026 Date 03/16/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 p + Vanguard Laboratory 1 2635 Parkmont Lane SW P. '0 e Olympia WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY Collected by: American Pump and Drilling Matrix Drinking Water 360-754-7867 Laboratory ID: V260106-37 Sampling Address: Date Sampled: 1/6/26 12:00 1170 NE Hurd Rd Date Received: 1/6/26 16:07 Belfair,WA 98528 Date Reported: 1/9/2026 Sample ID: 1170 NE Hurd Rd Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V260106-37 Analyst:IT Coliform,Total Negative 1 1 MPN/100 mL 1 1/6/26 16:58 E.coli Negative 1 1 MPN/100 mL 1 1/6/26 16:58 Nitrate by Hach Method 10206 Batch ID:V260106-37 Analyst:ZA Nitrate(as N) ND 0.50 10.00 mg/L 1 1/6/26 17:50 Notes:Bacteria growth present but not identified as coliforms. MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 01/09/2026 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 01/09/2026 DF:Dilution Factor 1,111..`217025:2017 MCL:Maximum Contaminant Level �� ACCREDITED LABORATORY 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 • WATER WELL REPORT DEPARTMENT' OF NoticeoflntentNo. WE61701 ° ECOL0GY Unique Ecology Well ID Tag No. BPD990 Type of Work: - State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission r=I> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic ❑Industrial ❑Municipal Property Owner Name PBK Construction LLC ❑Dewatering O Irrigation ❑Test Well ❑Other Well Street Address 1170 NE Hurd Rd Construction Type: Method: C]New well O Alteration ❑Driven ❑Jetted ❑Cable Tool City Belfair County Mason ❑Deepening C Other ❑Dug O Air- ❑Mud-Rotary Tax Parcel No. 32213-43-90162 Dimensions: Diameter of boring 6 in.,to 252 ft. Was a variance approved for this well? ❑Yes ❑e No Depth of completed well 249 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I ❑ 6 in. +2 244 1/4 in. (] I ❑ DID Location(see instructions on page 2): ❑WWM or❑EWIvl ❑ I ❑ in. _ _, in. ❑ I ❑ DID SE ''/,-'/a of the NE_ %;Section 23 Township 22N Range 3W O I ❑ in. _ _ in. ❑ I ❑ O I O ❑ I ❑ in. _ _ in. ❑ I ❑ IDIO Latitude(Example:47.12345) 47.39136 Longitude(Example:-120.12345) 123.00392 Perforations: ❑Yes 0 No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated front ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑O Yes O No E.K-Packer ' > Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works __. Material From • To • Type SS Tele Model No. 0' 4' Diameter 5 in. Slot size 12 in.from 244 ft.to 249 ft. Clay loam-brown Diameter in. Slot size .in.from ft.to ft. Gravel,sand,clay-brown 4' 176' Sand and gravel-brown 176' 197' Sand/Filter pack:O Yes ❑■ No Size of pack material in. Gravel and sand-brown 197' 239' Materials placed from ft.to ft. Sand and gravel,waterbearing-brown 239' 249' Surface Seal: O Yes ❑No To what depth? 18 ft. Gravel and sand,no water-brown 249' 252' Material used in seal 3/8 Chip Bentonite Did any strata contain unusable water? ❑Yes O No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: Sumbersible H.P. 1.5 Pump intake depth: ft. Designed flow rate: 10 gpm Water Levels: Land-stuface elevation above mean sea level ft. Stick-up of top of well casing ft.above ground surface Static water level 189.50 ft.below tap of well casing Date 1/2/2026 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ❑No Ell Yes : by whom?APD Yield 12 gpm with 21.5 ft.drawdown after 2 hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with- ft.drawdown after hrs. Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level 0 211 22:00 189.5 ➢ate.ofpumping test 1/6/2O26 Bailer test gpm with_ft.drawdown after_hrs. Air test 7 gpm with stem set at 240 ft.for 2 hrs. Date 1/2/2026 Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes ❑No Start Date 12/30/2025 Completed Date 1/2/2026 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❑Trainee❑P —Print Name Daniel Carpenter Drilling Company American Pump&Drilling Signature -;---)• v Address P.O.Box 14996 License No. 2236 City,State,Zip Tumwater,WA.98511 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.AMERIPD781JK Date 1/7/2026 ECY 050-1-20(Rev 08/19)If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.