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HomeMy WebLinkAboutWAT2026-00084 - WAT Application - 5/14/2026 vv t1 1 L J O-U' UO' MASON COUNTY COMMUNITY DEVELOPMENT - �a Q 0: Permit Assistance Center,Buitding,Planning 415 N 6t"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 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: Applicant! Parcel Identification Name on Applicant: John and Jan Bennett Date: 4-14-26 Mailing Address: 204 Euclid Ave., Shelton, WA Phone: 360-490-3468 Parcel Number: 32007-14-90043 Type of Water System Reason for Application ❑ Public/Community Wafer System (2 or more Building permit BLD2026-00336 connections) O Division of land: Individual water source(one connection), #of Parcels? SPL 14 Well ❑ Boundary line adjustment O Spring/surface water ❑ Other(explain) O 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. ❑ 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 4-14-26 This form may be scanned and available for public view at www.co.mason.wa.us. J:1EH Pormsl Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth 79 ft. Well capacity Test(attached to application) 5-17 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. Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA httlp://gis.co.mason.wa.us/planning 14[15[]16O 22= •Water use or limitation recorded................................... N/AA Yes_f 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) N 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_ U 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 5/14/26 CSD Director: Date 2 oft , ltifuticetieletenit^lo:V1tE47i62 WATER WELL REPORT . ��O LQGY Unttjtie EcotoFy t�eit ID Tag"Na�Nx2" 1. Typoof�Yorkt 5takt of i'lash#nggotti .° tlnstrpktioss; ite Well;Nome(iF more than ttne ti�c(1), 7,D otttmission r Clripiaattrsstaflakton (}ilFo; :.. WaterRigtsk"PemiitlCediftcate,Ato. • Piroposeii fle:' l 1 l otnesUe ci lmiuetnai, CI M n ripai Monroe ci Dewakenng C]1ni Clan #I T<sl: `ei! r. Well Strbt Address Hiawatha Stvd Gan krtrctlou'fypei i42erltorlt itySht3it0n •(oRnty surf!. £]ACacratia , Ci,f}m cti ti Dected'q t:abkToot t J tkpenmg C]gtii r O`.D6g' 11 Arr•. 13 hWd•Rotaiy Tax 1'aregiNo, 32(H37-14.9OQj3 A menelons:UearztCrar albssring B. ia,ig 7Cl 11.: kWtss'a variance acpproycrl Crsr tl}rs:�r 112 O Yes C"1"Ub: Depth oraa$feted r ell 7 IL G'�nstrocnoss DcrttCts 5Yali lfyes wiiahws lhe:variance for?. Caseng t isrei f3raaireFCf< Fsom To ThkI(s s 5I<1" .PYC:Weldcd Thtcad . L1 1 0 6 ,ut: 0'. :625 in i3}" I, C} Q .'I ;Cl Location(see instruutionsbn page 2) 1l W1'M or C3FWM' a t CI in; T _ an: Ll j" tO .O j :O SE 1%-rl.ofihe NE %. Section 7 Totvns tip ZaN 'tiacge. f C7 Cl lit . i a LJ '� -Q Latitude(Example 47 12345)!!7 239297 .� ; qn< _ � Lofigittidc(Cump)c:-124.12345}, i2 .t)9$Bt)7 t'erFormliontl O Yes flq: Type oCptrlaasor u pt itic7r'z.I aConstruetlan or I7e Glmnrtssion Prveerture. No ar pen tsons �. Stzeofperfaettaotts _ it by:�_ in pe - Fornsatson.:rksnFse by color eFsvactsrxize ornatenat ar1d st[tt€tsar4,asm the kind and fcrforated from It to , ...it bct w gravodstuCxco the terka is rash tayac rusted.tivllect least ease y frx each cl}anggpf natusa of tna Aqc Screen+ [7';Yes i 1 Ne 4=3:t Pat s$ Depth' _ C! Ifl6lii53titifl. Use addiliotaal shoats ieneeeas y; MausracttaercAtame Motenai, From, To v T3 Model No :Fliameter Slat'size ___....tit Crosts" _ rk to _-_ft: Broom sil sand and ravel Brown stltt ;ond sand and ravel,tight 3 15 Tjiatrituer „ Sint she i�Cram _.�._1l,ro Brown silty send and. ravel,loose 15 33 Saadtiiifte r pne#:L7 Yes f1 t o Sizeofirtets adakcriat' iia: Brown medium sand,; ravel loose wet 33 3$ Matenats plamel Crow ft,to r_;it Muiticotored gravel,medium to coarse brown 38 SurCnce . it ®"Yes.it]Na Tgtvhat`depdtiR 19 tt; sand;lab e,water 7'9 .Metenal used to seat Bentontte G1ns Did any strata ceatsiu unusable walei? O Yes Ar• a Fe olwat Grgp$ioftrata o ;Afe edots<alanttraro'eff .. _.. . • • !rumps i lanulacturer`e Aiotne Type H P;-Pump sale!o d skh._ ,il Designed how rake.'+glr! Water Leels f.nd-soars eloeatt n above mean secs leeet 2A0 ft.: Sut=uportopQu ellcaeng JL C.abuse gnawid'stye e Static aterlcret 2't. ft Wow Date 5111122 Meson pecseure lbs.per square inch Date ... c s1egsan water is etettrelted by (cop,valve urc) w tl'featss Was apmaprnglosk[ CQnnedF 1'710 C1Ycs r bj lstam4' ... . . ., :! ...._ Yield`_gpsu with il:drawdoa after_'tu4 Sseld _.,_,-.gpnwittl It drsksxtoavnaCnr,_,__his p 'a'seld gpm'tWtkFr ft dasvvtllosvaaRer firs da#a vase�xea cabers +ass tzusra klofr tiaaacrlevel"nteaeur d t'rwi well Time Water Tines p,rtc4or�try t P topxo x ten react) f ,,- lwpt¢:r 6ev+₹G Tilers, Water Level • :---�-`: =-^—^ .... .. .. - ..• , ._.. .. .... Dataofpuusprngtest: 6asiertest PRmwith ILckavcdosr+Oaler*`lies _ . lsirkesr 2Q Rpmtivithatemast t$4 ,CL ror 1^ �.ttrs 1 ato 5111122 At• tesiaa tlos� EPru empeeaturo fifty ter'5 11 .Q v \'as ri cho r wueat salt's s male? . F Yes 1=Ya Start:Ueate 5111122 Completed Diito<5(11(22 WILL GOY 1 RUC LION`CERT1P1C A f 1O? :1'cnnstruekcrt nndior accept tespoasibility for congtrtteflon oe thus swll,and its cumpiiaCtee with all WpshJugto"n;ry tt eoctskntcttort sl n urds Malcri sts used and fire"sttftsnetatlon repotted of eorettueto my heel knot edge and bdk1 l Driller.Q Trainee©Ph-Print Name osh Koe A Dry ConspafY Arcadia Qriliing Inc. Si nature.. , . • • • Address PO Box 17.90' City,State Zip Shelton WNA"98584 License Rio.287 .�: �,.._F ...: . � , Contractor's IF Rr11NEf�S vnsor'sLieen o... Contra:c nsor*siignstktre ^tiegisrrntlorCNo Al2CATlt}lU9$t{i fJtik1i12? ELY O50.120(tiro tk91i 8) ljyxsrr;rtexrl tkix tlocuiiieiti.tn air c?ldet+aale jarnrtrt plegsc,call the Ilea r� soar ces Pa a rxtarr rtf 3fGU t1? �r1; 1'evstzus with lrerrrfrag"rue's tnir call 7l1 %z f!oalltygtoit"lt€tr Sanlre,;Nelsons with rrspeeclr disabiNry,cntl cKll '2 83 t i Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Keith Monroe Well Tag#: BNX221 Phone: 971-344-0390 Depth: 79' Well Site Address: Hiawatha Blvd, Shelton Pump Set: 61' Date of Test: 5117/2022 Static 20.7' TIME GPM LEVEL RECOVERY 1 Min 5.0 21.4 TIME LEVEL 2 Min 5.0 22.4 1 Min 21.8 3 Min 5.0 22.9 2 Min 20.7 4 Min 5.0 22.9 5 Min 10.5 22.9 6 Min 10.5 24.0 7 Min 10.5 24.3 8 Min 10.5 24.5 9 Min 10.5 24.5 10 Min 13.0 24.5 15 Min 15.0 25.8 20 Min 16.6 26.5 25 Min 17.0 27.3 30 Min 17.0 27.9 'Vanguard Laboratary• ° 2635 Parkmmont Lane SW,Suite A Olympia:WA 98502 r rOy 360 967 7410,:, . Ct?LtF{ R I BACTERIA ANALYSIS FORM Date':Sample Collected Time Sample County. Collected Mason 03/18/2026 3 0 oAM Month ..Day Year TyPerof Water System(c heel TOnlyorie box) O Group A 0 Gfoup B jI Other Group,A and Group B Systems—Prov defrom Water Facilites Inventory(WFI): IN system Name: John Bennett Contact.Person:Arcadia Drilling,inc. Day Phone.(360 -)42&=3395 Cell Phone:{ ) Email: Ever Phone:( )_ Sdndtesultsto(Print,fail name;address and zip code ore-mail) arteta@arcadiadflling'com AND Jahn@arcadtadnllmg coin SAMPLE INFORMATION Sample collected by(name):.Shad Specific location where:sample collected Spbcial instructions or comments: BNX221 -100E:El Fuego Or,Shelton Counts please Type of Sample(select only one type asample from types 1 thrbugt 5below) 1,.O'Routjne Distribution Sample(NP) 2.0 Repeat Sample(AIP) Chlorinated:Yes- .No _ (from distribuion..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(NP) Chlorine-Residual:Total_Free___. O Assesst ent (NP) d;,•Surface or GWI Raw Source Water Sample:(Enumeration) O E.coil ❑Fecal. F tiered,Yes.___,No,_.,. .5. j SampjeCollected,forlbformatjon Only: LAB;USE ONLY' DRINICING`WATER RESULTS LAB:USE ONLY Dune sfactory Total Coliform„Present and SIG Satisfactory ©E.cati present .O Ecoli,absent Bacterial Density.Results:T tal Coliform <1.0 /100m. Ecoli 11.0 .t30Om. Fecal Califon '110Cml. HPC / 11 mf. Replacement SampleRequfreds O TNTC .O Sample tdo old '.Sample Volume. O Damaged Container O efrime' acetdod: La Reference umber . 4 a1 'Recelptrernpc':. taet cdCode: SM9223B -Date Reported to DOH Lab Use Only: .OOH Lab-Sample#. 285-t3 5'-2. 4MKcuu03313maieram00Jt7)kltycaRYA,a,p aa0as ma.id'.anaira0`mat'can5m.523.012 00 tY*Ul0t. `ns is sepia a5 ase:avie�sare slwwdrildtwsgar. irk's�Xwa!br,