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Home My WebLink AboutWAT2026-00073 - WAT Application - 4/14/2026 WAT 2026-00073 415 N.6th Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,.Community Health Elma:360-482-5269,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 on Applicant: michael lovely Date: 04/14/2024 Mailing Address: 1811 padrick rd centralia wa 98531 Phone: 3602920909 Parcel Number: 320052390046 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more O XBuilding permit BLD2026-00296 connections) 0 Division of land: Xlndividual water source(one connection), #of Parcels? SPL XWell O Boundary line adjustment O Spring/surface water ❑ Other(explain) O Other(explain) If you have more than one residence connected O Replacement or Remodel (please indicate name 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) O 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:\EH Forms\Drinking Water Revised 4/4/2018 Individual Water Well ® Water well report(attached to application). Depth— 69 ft. l Well capacity Test(attached to application) 13 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. Reds 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). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 15_16_22_ Water use or limitation recorded................................... N/A_____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) I" 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. O 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: Environ. Health: Date 4/21./26. This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 I- 0 °- - WATER WELL REPORT CURRENT Original&la'copy—Ecology,2o°copy—owner,3'd copy—driller Notice of Intent No.WE 12999 DEPARTMENT Or A, • ECOLOGY Construction/Decommission (a "in circle) Unique Ecology Well ID Tag No.BCR 678 W S,au o!wasNngwr. ® Construction Water Right Permit No. u ❑ Decommission ORIGINAL INSTALLATION Property Owner Name Robert&Kristy Rutledge :E SZ5 Notice of Intent Number ❑ Industrial O Municipal Well Street AddressMever Lake rd PROPOSED USE: ® DomesticP ❑ DeWater O Irrigation O Test Well ❑ Other City Shelton County Mason r- TYPE OF WORK: Owner's number of well(if more than one) O ® New well ❑ Reconditioned Method:❑ Dug ❑ Bored ❑ Driven Location S W 1/4-1/4 NW 1/4 Sec 5 Twn 20N R 3W Ewnt ❑ ❑ Deepened ❑ Cable ® Rotary ❑ Jetted (s,t,r Still REQUIRED) w Or C9 DIMENSIONS: Diameter of well 6 inches.drilled7l ft. Depth of completed well 69ft. S" CONSTRUCTION DETAILS Lat/Long Lat Deg 47 Lat Min/Sec 11'44" Casing ® Welded 6" Diam.from +1.5 ft.to 64 ft. Long Deg 123' Long Min/Sec 6'48" Installed: ❑ Liner installed " Diam.from ft.to ft. Tax Parcel No.(Required)320052390046 W ❑ Threaded " Diam.From ft.to ft. ♦+ Perforations: O Yes 0 No CONSTRUCTION OR DECOMMISSION PROCEDURE Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and O SIZE of perfs_in.by_in.and no.of perfs_from ft.to—R nature of the material in each stratum penetrated,with at least one entry for each change of information. (USE ADDITIONAL SHEETS IF NECESSARY--.) — ---—Screens:—O-Yes'- ❑-No—®-K-Pac—• -Location 63-FEET FROM TO MATERIAL Manufacturer's Name ASP Small to medium multicolored 0 tv Type STAINLESS SLOTTED Model No. gravel with silty day binder 4 Diam.5"Slot size.020 from 64 ft.to 69 ft. Small to medium gravel with 4 Diam. Slot size from ft to ft- fine brown sand,silt,loose 25 Gravel/Filter packed: ❑ Yes ® No Size of gravel/sand Small to medium brown gravel 25 , Materials placed from ft.to ft. Orange Silt,wet 27 J..t Surface Seal: ® Yes ❑ No To what depth?18ft. Small to medium gravel,firm 27 Material used in seat Bentonite Chips brown sand,dry 30 ( Did any strata contain unusable water? ❑ Yes ® No Multicolored gravel,medium 30 L Type of water? Depth of strata brown sand,water bearing 42 Brown fine to medium sand 42 Method of sealing strata off few gravels,wet 57 PUMP: Manufacturer's Name Small to medium multicolored 57 Type: H.P. d gravel,medium brown sand WATER LEVELS: Land-surface elevation above mean sea level all ft. water bearing 69 Static level 16ft.below top of well Date 06/14/2011 Small to medium brown 69 O Artesian pressure lbs.per square inch Date silthound sand and gravel 71 Artesian water is controlled by (cap.valve.etc.) WELL TESTS: Drawdown is amount water level is lowered below static level 0 Was a pump test made? ❑ Yes ® No If yes.by whom? QYield:__gat./min.with_ft drawdown after hrs. fl '� II ' () Yield: gal./loin.with_ft.drawdown after bra. n .roc o . LU Yield: gal./min.with ft drawdown after hrs. I Recovers'data(time taken as zero when pump turned oJJ)(wafer level measured front Lt1 1 well top to water level) '�'r Time Water Level Time Water Level Time Water Level SA IA A t;+n a` .r f __tit voa•v• ... r- .E-- _ o_.., t trnn Ui ct,�lvyy k%jv 5 5 L Date of test C Bailer test galJmin.with_ft.drawdown after_tus. Airtest 30 gal./min.with stem set at 50ft.for 1 hrs. U Artesian flow e.p.m. Date Start Date 06/14/2011 Completed Date 06/14/2011 Temperature of water 50 Was a chemical analysis made? ❑ Yes ® No 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 'nformation reported above are true to my best knowledge and belief. 0 Driller 0 Engineer Trainee N e t Jos oe Drilling Company Arcadia Drilling Inc. !hiller/En ineeriTrainee Signature Address Po Box 1790 Driller or trainee License No.2874 City,State,Zip Shelton , Wa, 98584 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. ARCADD1O98K1 Date 06/23/2011 ECY 050-1-20(Rev 02/10) Jf you need this document in an alternate farina!,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. MOERKE& SONS PUMP & DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST COUNTY LINE DEVELOPMENT 3/16/2026 WELL SITE ADDRESS: 541 EAST MEYER LAKE RD,SHELTON WA 98584 Pump Make&Model: Pump Set At: Sounder Make& Model: Make&Model: MASTER Measured in: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 0 156052 15.4 400 GAL.TEST BAGAN 1 12 156065 15.4 2 13 156078 1.5.4 3 13 156091 15.4 4 13 156104 15.4 5 13 156117 15.4 6 13 156130 15.4 7 13 156143 15.4 8 13 156156 15.4 9 13 156169 15.4 10 13 156182 15.4 15 13 156247 15.4 20 13 156312 15.4 25 13 156377 15.4 30 13 156442 15.4 35 13 156507 15.4 40 400 GALLON TEST END SIGNATURE: RKE AN UMP AND DRILLING • f Vanguard Laboratory V 2635 Paiicmont Lane SW,Suite A Olympia WA 98502 q e B 360-967-7010 GN02I I F04 COLIFORM BACTERIA ANALYSIS FORM OaleSentpteCoileced I TfineSa we 1 Csuniyr C 3 1 l b11 b cOeded • 4 Nam n9' YAW Type dmier>ystem(died mdycne bmt) ❑Gmup A ❑Grai*B ether PV's GmupA end Gmup a 3ysteis—Presrtde from WakrFaafEos tnumtory{tNftk 105 s°"' cot L' cto Conladfl�rsca: .�}�. w. H. 14th' Day Phone:( ) Ce3 Phone:( ) t-met EYe Phone:( ) Sand+�ils bb(Phdti9l rmmrn add�essandripcode aremsM t Ob Ill 1L6L Nh S-. tc. vt SAMPLE INFORMATION SampleeoRectedby(name): faw`.tS q:LK,'.. sOfv� Spedfcierafienwh¢resao1pla 1ec�d: trsbutionsare mmeni L(j � �' JV tyt!L�JGe i4b' w41S Type of SmVe(sdadonyo=Weofeample fmm types I Ihragh 5 blow) t.❑Routine Dlat,hudon Sample(AIP) 2.❑ReptS3upi(Alp) Cht dnatad:YeNs ftmewtustlw+Syalematl&W al.ID ) ChtadnaRoslduai•Tota1—,Fray___ U ° muthelobmm�ber. 3.Groom Water Rule SourceSam a --"— -—"^-- Uasat�facmyroid eedleddate: S _J Odofinatet Yes No ❑T ) Cldoi eResidmk TetaL_Frae ❑Msesament(NP) 4.Surface or GWt Rash Somme water Sample(Fiemnma6on) SI ❑E ❑Feat rwa Yet_lb S SQmptetYdt torlafart4atlon0aly: LA 13 USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Cann Present and 7�7 ❑Ec umsent ❑Ecoliabsent Baetodai Dens iq f ResmHa:Total Coifomr H00mL Eec �0QmL Focal Q0rnl. HPC 11 MI. Replacement Sample Required: ❑TNTC ❑Sample too old ❑Sarrplee: ❑Damaged fbnter ❑ca ` ^� ifgE rcMiNomw Qf)OPdfl3fl—`—1 V Ren lTewPC'3 .1 Z SM9223B hateliepartedbDDH tabUse0n!p C0H Sarnpt� 285-01-' 90 owireamwnt me+er aswasa.mrrmrrrmna nh.amanem'Er.dmtanstie Vanguard Laboratory 2635 Paricmont Lane SW,Suite.A Olympia WA 98502 360-967-1010 V ZCd3 1 l 1 — 5\ VO UARI D aaoewaxaxr 1�Bta�atNitrite Analysis Report Date Collected:(MM/DD/YY) 3/(&/L System Group Type:(aide one,) A B Other Water System ID Number. Syem Name:COV L &t. ee1opse"l Lab Number/Sample Number. 2. sJ Li Gou . a y% Sample Location VfI ge,&M.tye.c t-o %tt.9-I Source Number(s) (lutausourcvsrrrdendedorcompasmedJ Ski W t S Sample Purpose(check appropriate bar) Date Received: (MWDD/YY) Q� ❑ RC--Routine/Compliance(Saashes monitoring rerp+i►ementsj Date Analyzed: (MM/DD/YY) Q 11JLL ❑ C--Confirmation(corrNmatlon of chemical resuW* Date Reported: (MM/DD/(Y) 1, /2 [(I—Investigative(Does nor sad*monitorirrgrequirementr) COMMENTS: ❑ o—Other onnotsu<tsfyman8orir(q bmenisl ;?SPS--Mngle (e Composition(check apprapnale bwr) Sample Type(check one.) re-treatment/Untreated(Raw) Source O Post treatment(Finished) ❑ B--Blended(Latsorme numbers hr Source Number?field,) ❑Unknown or Other ❑ C--Composite allscurce numbers in Source Number?field) Sample Collected by.(name) WI. S b&MI& IA ❑ D—Distribution Sample Phone Number. Send Report to: Bill to:(Client name.) &L&tis ..1A-' S.?L Analytical Results Data Exceeds MCI. Method/ DOH 8 Cvataminant . Qua1Rier Results MRL SDRL Trigger MCI. units (X If Yes) initials 0020 Nitrate-N 1,19 05 05 5.0 70.4 mqfl. Hach 70206 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 mite. Data Qualifier:A symbol or letter to denote additional information about the result DOHW:Department assigned contaminant number. Ei seeds MCL(Mardmum 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. MEI'HOD/IAIITIAL&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 minimian reportable detection of a eortteminantas established bythe 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 VanguardLaboratary• 2635 Perlmont Lace SW,Suite A Olympia WA 98502 360-967-7010 V 200311 - ' 1 � eaAR D saneaaroo�r Nitrate te Analysis Report Date Collected:(MM/DD/YY) 3/i&/i-b System Group T one) A B Other Water System 1D Number. —---- S stem Name:C D V Le c, r Lab Number/Sample Number. 2 l l- l ountyA.i. bto Sample Location L&(l 6as4' /Ittrytr t- i.Let0.Q Source Number(s) (baldlsoru�esifhkndedor=npwiaedj Ske. W Ss Sample Purpose(chedrappropriatebW Date Received: (NMLDD/YY) QJ t ]J.L ❑ RC--Routine/Complance Date Analyzed: {MM/DDIYY) 0 1 1J2Q.. ❑ Cr—Conftrmatlon(Confirmation of dremiwlresult7 Date Reported: (MWDD/YY) D. L..9 J�� WI—Investigative(t)oesaar eis{ymont7orfingRqureraents) COMMENTS: 'L L . � ❑ O—Other(5pecrfj--doesnotsatislyman requirements) ;?:PsLfngle omposition(check apprapt(ooe box,) Sample Type(C had-one) re-treabnent/Untreated(Raw) Source ❑Post-treatment(Finished) ❑ B—Blended Ristsourcenumbersin'Sowre Numbers!leld,) Olin known or Other ❑ C—Composite(L(st source numbersin source Numbers field) Sample Collected by:(name) T u& S t Ju.[o V1 ❑ D—Distribution Sample Phone Number. Send Report to: Bill to:(c&eatname) Analytical ReSnits Data 6aeeds MCI.? Method! DOH S Contaminant . nualiter Results MR!. SDRL Trioqer MCL Units (X if Yes) Initials ouzo 4 aatQ.N trite as N ND R5 05 5.0 10.0 m Hack 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 DOHIb Department assigned contaminant number. Exceeds MCL(Maximum Contaminant Level):Marked if the contaminant amount exceeds the MCI.under chapters 246-290 and 246- 291 WAG If you have questions about this result please contact the department's drinking water regional office In your ales. MEfHOD/1NITIAl&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(Stet.Detection Reporting limit):The minimum reportable detection of a eontaminantas established by the department Trigger.The departments drinking water response level.Systems with contaminants detected at concentrations ator above this level may be required to take additional samples or monitor more frequently. LAB COMMENTS Revised December 2021