HomeMy WebLinkAboutWAT2026-00075 - WAT Application - 4/21/2026 WAT 2026 - 00075
415 N.6`"Street
Shelton,WA 98584
Shelton:360-427-
Pub ,Ext.400
lic Health & Human Services
Belf&:360-275-4467,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part I 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: Applicants' Parcel Identification
Name of Applicant: a t reeve Date: ?
Mailing Address: E St Q4- 3 U& - Phone: 425 • 9OroI
Parcel Number: 11'2 ��•74"t®0'4 t A c2.1
type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit BLD2026-00297
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
Well O Boundary line adjustment
0 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 wjriem has been approved for services.There
are presently connection(s)in ue. This will be the connection.
o 1 am the manager of this system.T i connection will be to upgrade or change the use of an existing
connection on this systemA creational to full time). Please indicate on the following line the nature of
this change:
This water system i le and willing to provide water to this (these)connection(s)without exceeding the
limits of the wa system or any limits set by state and local regulation.
Print Nam f Water System Manager Phone
Si tore of Water System Manager Date
This form may be scanned and available for public view at www.masoncountra.gov
J`\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test withi t year(attach to application).
Individual Water Well
Water well report(attached to application). Depth 419 ft. 12/06/2025
fA Well capacity Test(attached to application) 1 0. 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. 12/06/2025
l Satisfactory bacteriological test within last year(attach to application). 12/16/2025
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source n provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per m' to based on the following observations.
Author of Statement Date
Relationship to App nt
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.
0 Unsatisfactory.Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s)-
Eli APPROVED Reviewer's Signatures:
Environ. Health: .Anderson 04/21/2026 Date 04/21/2026
This form may be scanned and available for public view at www.masoncounty—w-e.aov
Page 2 of 2
WATER "EL.L REPORT DEPARTMENT OF Notice of Intent No. WE61175
ECOLOGYUnique Ecology Well ID Tag No. BNM834
Type orWorlc: State of Washington
Coueuuction Site Well Name(if more than one well):
0 Decommission e onginalin llationNOiNo. Water Right Pertnit/Certificato"No.
Proposed"Use: D Doratstia ;."3 industrial ClMunicipal Property OtmerName LEGACY HOME CENTER
O Deweterme 0 Irrigation Ll Trot Well 0 Other
Well Street Adrires NE SAND HILL RD
Cu5tructioa lypa Method:
A New well Cl Alteration: rl Driven 1 Jotted. O Cable Tool City SELFAIR County MASON
0 Deepening Cl Other CI Dona A Air- O Mud-Rotary Tax Parcel No. 12307349004
Dimensions:Oiametcrofbosiag 6 in.,to 419 Was a N-ariance approved for this well? 0 Yes 93 No
Depth of con pletecl well 419 ft
Construction 3rctst7s: Wall If yes,,what was the variance for?
Cnzmg Liner Dsiamewr From To Thickness Steel PVC Welded Thread
I i~7 6 in. 41x1 .250 in. - 1 0 an 1 O Location(see instructions on page 2): AA'WWMor 0 EWM
O O in in. O ( 0 M I 0 SE ofthe SW Ye Section 7 Township 2813 Range- I
t i 0 ire. __ in. O 1 D El I
• Gt i i , ,_,, in, i 2 1 r ❑ 1 i� Latitude(Example:47J2345)47.49 712
Longitude(Example:-120.12345) -122.8570
Perfuretoaw 0 Yea A No Type ofpezfnrator used
No.ofperf rations . Size of perforations in.by in Driller's Log(Consiruction or Decommission1'roeedare
O - Formation:Describe by color,character,size oftnetcrinl and suuctorc,and the kind and
Perfarnted from ft to" ft below gtound turtle nature o£tha material:in each layer paaetsated,with at leaat.tmc entry foreach change of
Screens: A Yes f i Ne A& Pao&er Depth-£e information. Use additionai sheets ifezzeessary.
lsfan ••tnser's taame Material Pi'otn To
T' STANLESS Model No
N , - CLAY&GRAVEL BROWN 0 I90
Diaaueter 6 "tts. Slot size 12 in.than 414 }��to 418 �,
+'s- Diameter i.. Slot s ze___ in from fl.to ft CLAY BROWN 190 200
CLAY&GRASVEL BROWN 200 215
O Sandi Filter park:E'sYen A No Size of peck:minrial_i
o hfntesials plastid front ft to__.&. CLAY&GRAVEL BLUE 215 230
CLAY&GRAVEL BROWN 230 320
Material
ed. n fes N 2b T'o whitdepth?20 3L CLAY&GRAVEL RED 320 405
1 tersai used utscal BEKTONiTB
cDid any strata contain unuseble'wyater? lD Yes. A No GRAVEL H2O BROWN 405 419
Type ofwater? Depth ofsmta
Method of coating strata oil
pump:Mannf 1 aura's tinter GOU)LDS Type: SliP 3PH
it?. S Pump:intake depth:413 & Designed flow rate: 9 fA gpm
Water Levels:Lendseiffececlerationabove atone sealctef £t
Stick-up of top ofwell casing i R.abevc:gouudaustere
Statiewater level 362 ft.below top of well eating Date 12-12-25
Artesian pressure_.. .3bs.per square inch Date
+ Anesizr water is controlledbti' (cap,valve,etc.)
C
Weei Testst
Were a pumping tesi perfatmed? 0 No G Yes c by whom? RE EtVE1
Yield 1Q gpm with.L ft drawdow e arer 4 firs.
Yield gpm with_ft drrwdown n&er tea.
Z Yield_$pro with,__ft dmwdown after_„_,__tus.
in Recovery data(Bosse=zero wlteupumip is turned off-water level m sired Item welt
N top to water level)
Time Water .evel Time WreerLevel Time Water Level
5 362
O
to Date ofgumpfng test
Baer rest - Spar with:_,_fL drawdowa after lvs.
*- Air test____rpm wide stem set at,_,_ft.for firs. Date
Or" Astalenfloai' gpta
Tamparatneo ofsvater mP Wss aehemienl atmlysu made? C Yes 18 No Start Date 10-28-25 Completed Date _12-6-25
O
ta. WELL CO+TS'IRU`CTION CERTl 11C ATION: I constructed and/or accept responsibility for construction of this yell,and its compliance with all Washington"tiall
4 construction standards.Materials used and the information reported above are true to lily best knov1edge and belief.
9 Driller:11 Trainee O en sore CLAYTON PITTS Drilling Company COOLWATER DRILLING,INC.
Signature Address 10921 NW HOLLY RD
License Na.2516 City,State,Zip BREMERTON WA98312
IF TRAPNEE:Sponsors LicenseNu. Contractor's
Sponsor's Signature Registration No_COOLWD194IQM Date 12-23-25
EC1"050-1-20(Rev 11718) Ify=ou need this'docun ent in tin a!iernare fonear,please call t tt WaterResources Program at
360-407-6872. Persona ivkh Juosermg loss can call 711 for pl zskington Relay Service. Pervnras-ith a speech di.w.blliy can call
877-833-634X.
221 wvty
Ytv"Li NW
s:z+c ! l+hst'')'RA l.ubr�lxur►riC� a Kits;xp
�oulaiv,lv 4,
(xo)nvta) . COUFORM BACTERIA ANALYSIS FORM ".,.
Casa zo 00l'o JWT Yume�+ut/(+lo tirunQ
�►yw�r1 Dot v. j
C1 tyry of�Sd Il
Group A and CAW a Sys%m-Pww4de 1M,WaW Fa uko Inft"(WF�)
I.
CmtctPe+son: cav(r,,,*Fit
Dayptgtw. to $3D_ yaO�r Cell
Emat cootw,#,mt Att--T e-. l+4�7ctiIFi C, co.
swdi*k b a raiu.a.�.►. ...erbaaa.)
SAMPLE INFORMATION
Sampte cc ec d by(nmm) t wl
Specic bcafm sample c ecbd Specet Yubucda s or camnronk
j,4r !'�xtt. Aj
Type of Sample(dhedc OY ana box)
t.0 Roerttae DisVibuUon Siaxpie A ) 2.❑ Rpost Sample(NP)
Ct torinated vex❑ No❑ Rom di° 'aa`ra"ow WISA Mwo)
lk s4cb y routine bb nwfier.
Cttbrba Raeidxat Tots___Fmc._,.
3 Grw:+d Nat r Ruk Sours Sample Unso sd y routine oolect dale:
S ___ . 1.
Chbbbraled;Yea_ _ND
❑Tfpgaed(NP) Chlorine Rees Toet{._Free_._..
❑Aeeee'merd OM
i.SnRen of GW!Raw Samoa Water Sample tEnumerstlan) I e I ► I
Q E oaf 0 Fecal forme r«.._
, _srtctle Coeectrd h e+t"rxatlon Qeh/ ❑P I O Cone d lJ Rip +
LAB USE ONLY DRINKING WATER RESULTS USE ONLY.
(]tkssyrfsdcy Tow Comm Present and Sills
❑Emf pleeent ❑Ecolebsent
t wb"penalty Rsst I Tort C Tn ffVWl Wml.Ecof lmprVt00 Tt
F"Caiknn cWIOt 1t WC c lml-
Raptacas !Sample R.Qub.d. Cl TNfC ❑Sample too rid
❑Sampleyoirme 0 Darmped Consr 0
Tm9C. �t>. Wd L pi-0OtMfl5M9YdD` ..,...s»+.,M��W raw wr w►,xo
DON tIt 5/ a
I -_.�..��.. •tit H.iIv.I�.11wM.�M W�1Mr.
pDtvsBlta9Mr.�+mil ., _.