Loading...
HomeMy WebLinkAboutWAT2026-00053 - WAT Application - 3/12/2026 WAT O ? C -MASON COUNTY 415 N.6"Street Shelton,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 Name of Applicant: DAVID& HEATHER SWEET Date: 3/12/2026 Mailing Address: 1902 S STATE ST SEATTLE WA 98144 Phone: 360-994-8801 Parcel Number: 322075000915 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more Building permit . [1 2102,& connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL 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. ❑ 1 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:\EHForms\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 200 ft. Well capacity Test(attached to application)_ 12 gpm r >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. 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 appilcable WD0E 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 ROW. ❑ 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: -.Health: 4/10%26 Environ. Heallth: Date This form may be scanned and available for public view at www.masoncountywo.gov Page 2 of 2 WATER WELL REPORT Dt PAZTMENT or Notice of Intent No.WE445O8 ECOLOGY Unique Ecology Well ID Tag No.BNA 146 ,rypo orW'ork. S:st.of 4vashingtrn [P] Construction Site Well Nettle(if more than one well l: Deeaonnissian Original installation NOI No. Water Right PerntiluCertifteate No. 1'rnpased Use: LI Domestic ❑Industrial "')Municipal Property Davit r Nmne David Sweet 7 Dewiaering CI Irrigation Li Test Well ^'Other Well Street Address 21951 NE N Shore Rd Construction Type: alethod: (:it TAhtlya County Meson i New well ❑Alteration C'.Driven ❑Jetted .l Cable Tool Y tT O Deepening G Other 0 Dug 7 Air- J Mud-Rotary Tax Parcel No.32207-50-00915 DIntenslotts: Diameter of boring 6 in.,to 280 II. Was It variance approved for this well? U Yes O No Depth of completed well 200 n. C'nnutrudlnn Det ails: Wall If yes,what was the variance for? Gaging Liner Diameter from To Tbicknenu Steel PVC Welded Thread Cp-i 1 ❑ 6 in. +1 260 114 in. l ❑ (b] I ❑ Location(see instructions on page 2): 11 WWM or O EWM C7 I ❑ _ _in. — —in. ❑ I (1 ❑ I O NE '.4=t of the NE Section 7 Township 22N Range 3W ❑ I ❑ in. — — ---_in. Li O ❑ I 1 f $' o ❑ _in. _ ___ _ r in. CI I ❑ ❑ I Latitude(Example:47.23.15)47.414116 Longitude(Example:-(20.12345) -123.101347 l'errornllons: Yes O No Type of petfetattr used No.ofperfomtions 4 Size of pertmations.114 in.by 4 in. Dritler'u Log/Construetlon or Decommission l'rdcedure Performed front 125 it.to 130 It.below ground sorfnn: Fomwtion:Describe by color,chummcr,size of material and structure,and the kind and nature of tic ntntcrial in each layer penetrated.with nt tenet one entry lbr each change of Screens: O Yes n No K-I'aekcr b Depth,....._,..,.,.ft. iafunnutimt. Use udditiunul streets if necessay. Mnnufactawr's Nnnw Material Front To Type Model No. Diameter___ in. Slot size in.front_ft.to-n. Reddish brown sand&gravel 0 25 Diameter_____ in. Slot size___ in.front a A.to_._n. Red conglomerate 25 120 Water bearin gravel 120 130 Stied/Filler Inch:❑Yes ❑Na Size of pack ntatcrinl_in. Materials placed flour-IL It'-ft. Peat with streaks of blue clay 130 160 Red conglomerate 160 280 Surface Seal: Yes O No To what depth?2?II. Materiel used in seal bontonilo Did any strata contain unusable Water? ❑Yes ❑No Type of water? Depth urstrmo Drilled to 280.Sealed Lower bore hole with Method of sealing strata off bentonite to 200,Perforate pipe at 125-130. Ptltnp:Manufacturer's Name nrundfell Type:sub 11.P.314 Pump intake dupth:12O It. Designed tinny rate:1 0 Spat Water Levetat Land-surface elevation above meat tied level-11, Stick-up of top of well casing_ n.above ground surlitco Static water level 90 II.below top of wall easing Date Artesian pressure__lbs.per stlanec inch Dote Artesian wntcris controlled by (cap.vnhxt,etc.) Well Teats: Was a pumping test performed? Cl Ne L.Yes i by whoti! Yield—pin with_it.drawtlmvn oller�hrs. Yield—glint with—11.drawdowa aver_his, Yield.�Spun with_fl.drawdown alter—bra. Recovery data(time-zero tvlttn pump is timed off—scaler level measured from well top to water beet) Time Water Level Time Water Level 'Time water Level Date of ptmtping test Bailer test 10 Spot with20 ft.dmwdown anorl has. Air test�—Split with stem set at—ft.for_hrs. Date Artesian llow_grytm Tcmpernlure ofw•nter_"P Wan a chemical nnnlyris ntnde't CI ves I'1 No Start Date 4/1/22 Completed Date 4116122 W ELI.CONSTR4(:TION CERTIFICATION: I constricted anchor accept responsibility for coustnielion of this well,and its compliance with all Washington well cunstruction ntnudurds.Materials used and the infonnntimt repottcd above arc true to toy best knowledge told belief. ©Driller❑Trainee O PE—Print Name Emily Davis Drilling Compunv Davis Drilling Signature +/ __ Address 340 NE Davis Farm Rd License No.3142 City,State.Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Spollsof o Signature Regintralion No.DAVISDI11OOA Date April 2022 ECY 050-1-20(Rev 08/19)If rota need 1/i is docaawent is an allcrnate Jorwtu.PICast'rail the Plater Resources Prugrain a!360-407-6872. 1'ercan.e ivir/i hearing lace con roll 711 Ian Washington Rehm Service. Persons with a speech disahillh'rout call 877-X33-6.4.11. Davis Drilling 340 NE Davis Farm Rd Belfair, WA 98528 Date:4/7/26 Test Pump for: 21951 NE Northshore rd. Belfair Well depth: 200' Well tag: BNA146 Pump size:3/4 HP Static water level:86.3' Pressure: 50-70 PSI TIME WATER LEVEL GPM Om 86.3' 0 1m 93.1' 13 3m 99.5' 13 5m 104.2' 13 10m 108.6' 12.5 30m 112.4' 12 1H 112.8' 12 2H 112.8' 12 4H 112.8' 12 RECOVERY 1m 103.5' 3m 96.5' 5m 92.6' 10m 89.3' 30rn 87.1' 1H 86.3' On 4-7-26 I performed an inspection of the well at 21951 NE Northshore Rd. Belfair WA,98528. The system consists of a 6" drilled well, 81-gallon pressure tank,%HP submersible pump&control box. All components of the system are functioning properly at this time. 26276 Twelve Freon l.n N W sr�•�' ! SPECTRA (..aboratorics - Kitstrp Postlsho.WA \ 98370 ...Where ea rrlrnce mnnrra (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date S m to o lode Time Sample County "1 Collected �/]� Man(h Day Yoar Type of Water System(check only one box) ❑Group A ❑Group B 1Jihor Group A and Group B Systems—Provide from Water F cllitles Inventory(WFl): IDf1 System Name: Contact Person: ad ,S'& Day Phone: Cali Phone; (J Q Emoil: ,G� ltn Send rosuts to:(P1a ruu na a,nddross and zzii code :.$AMPL IN QRMATI0N.. y Sample collected by(name); Specific location where sample collected: Special Instructions or comments: c W/.7 ems( Typo S®mpla(chbckony one boggy' 1.®Routine Distribution Sample(AIP) 2.❑Repeat Sample(AIP) f1 Chlorinated;Yes ❑ No(I (from dlstribueon system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total—_Free 3.Ground Water Rule Source Sample ——_ Unsatisfactory routine collect date: Chlorinated:Yes No. ❑Triggered (AIP) Chlorine Residual:Total Free__ ❑Assessment(NP) 4.Surface or GWl Raw Source Water Sample(Enumeration) I „ ( ❑ E.coil .❑Fecal Flkared Yos_No_____ 5. Sample Collected for Information Only: ❑Pdvate Residence ❑ConstnldionfRepeks ❑Unsatisfactory Total Coliform Present and satisfactory ❑E,colipresent ❑E.coliabsent Bacterial Density Results:Total Coliform ,mpn1l00ml.E.coll mpnN00nrl.' Fecal Coliform _____cful100mi. HPC cful1ml. Replacement Sample Required: O TNTC I3 Sample too old © Sample Volume C]Damaged Container ❑ Dal a Roc prep d:, /r, ,/ dab Refer a Number P : / Receipt Temp C 1� Method Cad 1 SM92 10TT000NiISMO2220 sso wIt bum sae or pswso Uscenal QlgM1rt/ta ' Dalel Date Cu: whmruC daassM Amuse, aaaubsuedhuthan hyew h Yuadedro tdbwuus,McN.iy,thav+[kemWsrapalln• . 2' +G' um.pbaw m6rtrs sanaaYrrr�tllauyaaso-neaty as ,. DOH Lab-soploo _ �s desaoyedsrepatpraroW s�Iires+asnrot&xt the rep Wlsdmdthr*u (s es t rcodrodayVlaonatary.11darepoAshaOndsppraxwW; • Mn NhdlxfeaN pSQa�assn lov wutr epadrouGaaslaNs ooHross1tatepsaeuraoetn