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Home My WebLink AboutWAT2026-00086 - WAT Application - 4/7/2026 WAT 2026 - 00086 MASON COUNTY 415 N.6t'Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health +fit 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 an this application. Part 1: Applicant/ Parcel Identification Name of Applicant: NOLAN BENTZ Date: 04/07/2026 Mailing Address:4221 W EVERETT AVE SPOKANE, 99205 Phone: 509-999-2475 Parcel Number: 32120-75-00070 Type of Water System Reason for Application W Public/Community Water System (2 or more l;R Building permit BLD2026-00319 connections) O Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well O Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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 WEL2026-00007 Name of Water System: 490 WATER Water Facility Inventory (WFI) Number: NONE (write"none"for'two-party) EX I am the manager of this water system.The water system has been approved for 2 services. There are presently 0 connection(s) in use. This will be the 2ND 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 NOLAN BENTZ Phone 5099992475 Signature of Water System Manager Date. 04/07/2026 This form may be scanned and a ilable 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 EE Water well report(attached to application). Depth 100 ft. 05/26/1998 EX Well capacity Test(attached to application) 11.5 - 13 gpm 807.5 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. 01/22/2026 EX Satisfactory bacteriological test within last year(attach to application). 09/23/2025 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 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 IDAnderson 05/07=2(j Date 05/07/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of2 WATE R WELL R E P0RT Scare Card No, W101347 Unique Well ID. N AEC960 STATE OF WASHINGTON Water R.ighrr Permit No .,..,,.m.......z.,...n.................----.,------------- ---n........................,.....,.,.mnennneg__9r a._.-x.....x zw x.o........... ms�.aau� :;*cs_ tit OWNER: Name ADAMS, LAUREN Address PO BOX 1047 BELPAIR, WA 98528- ' ............................................................................ .avvv n-r-.a�_...__�—��..G�^^�aT_...n.ia R�mn4__.__......�_�§�." 12) LOCATION OF WELL: County MASON NE 1/4 NW 1/4 Sec 20 T 21H N,, R 314 NH i2a) STREET ADDRESS OF HELL tar nearest address) PiNBDARCSA ROnn, UNION ...................... ..................................... nom.-=--_-- -- -_-^- ^- - - __ ,_ =.............�=s_ _ (3) PROPOSED USE: DOMESTIC (101 WELL LOG 3 ...... ...........e...............................-----n.-.xx---=�--------- ------ {4) TYPE OP WORK: Owner's Number of well ( Formation; Describe by color, character, size of materiel (if more than ones ( and structure, and show thtak-ness of aquifers and the kind NEW WELL Method: ROTARY ( and nature of the material in each stratum penetrated. with --------------------------------------------------a************* * n= at least one entry for each change in foreation. (5) DIMENSIONS. Diameter of well 6 inches (------------------------------ -------- ------- Drilled 101 ft. Depth of completed well 100 ft. ( MATERIAL ( FR,)M { TO -----------------------------------------__x.. a.x _..a_�e..=.a........' PACSSSD COURSE SAND GRAVEL { 0 I 27 (6) CO(LS'TRt?CTION DFTArr.s - ( PACKED GRAVEL COURSE SAND BROWN CLPX ( 17 51 Casing installed: 6 " Dia. from +1 ft. to 100.0 ft. ( BROWN COURSE SAND GRAVEL ( 51 { 78 WELDED CASING Dia, from ft. to ft. ( WET COURSE SAND SONS GRAVEL ( 78 { 91 Dia. from ft. to ft. ] BROWN COURSE SAND GRAVEL & WA'ER 91 ( 101 -----I f Perforations: NO Type of perforator used SIZE of perforations in. by in. perforations frost ft. to ft. ( ) perforations from ft. to ft. ( { perfora'ion' from ft. to Ct. ---- -----------------{ { { Screens: NO ( E Manu₹acturer's Name ( ( ' Type Model No. C+ism. slot size from ft. to ft. ( ri- ` Diem, slot size from ft- to ft. ----------------------------------------------------------- ____ ___________ Gravel packed: NO Size of gravel ( ' Gravel placed from ft. to ft. { Surface seal: YES-----------------------------------------------------------ITo what depth? 20 ft, ( . ti I h Mareriai used in seal BENTDNITE ( ( Dd any strata contain unusable water? NO ( Type of water? Depth of strata ft. ( •� I hethod of sealing strata off T' + i 1 17)=PIDFP. NenufectureW's Name "` _ Type H.P. ( ( IS)^WATER wLEVELS: •••'_•'••__Land-surface elevation above mean son level ... Static Level 70 it. below top of well Date 05/26/98 Artesian Pressure lbs. per square inch Date Artesian water controlled by { work started 05/26/98 Completed 05/26/90 i...2i'x'C-^.:� f:.o..........R...............M....... ..... .,:n:'3nnnn(A.........................................QU..:.W.kt,.^.mac= ..aafi4='Rba#..^_Gc�_..............�x-.x {9) WELL TESTS: Drnwdown is amount water level is lowered below j 1•tELL CONSTRUCTOR CtRTIEICATION: static level. I constructed and/or accept'responsibility for con- Wan a pump test made? tro if yes, by whom? { struction of this wall, and its compliance with all Yield: gal./min with ft. drawdown after hrs. ( Washirgton well construction standards. Materials used i ( and the information reported above are true to my best knowledge and belief. Recovery data Time Water Level Tire Water Level Time Water Level ( NAND ARCAOTA DRILLING INC. ( (Person, firm, or corporation) (Type or print) { ADDRESS SS 17 AL1C Date of test / / Bailer test gal/min. ft. drawdown after Firs. ( (SIGNED) License No. 2053 Air test 40 gal/min. w/ stem set at 95 ft, for 1 hrs.J Artesian flow g.p.m. Date ( Contractor's Temperature of water Has a chemical analysis made? NO ( Registration No. ARCADDIO98KI Date 05/,26/98 a cce a.am��.ee.a_eoacaa�aaenm.................................................mac=tea.acs..�o�c_�cc=n�_nvvaava�a=�x=a=............. Printed a County Printed from Mason County O rM Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Nolan Bentz Well Tag#:AEC960 Site Address:490 E Pinedirosa Rd,Union Depth: 100' Date of Test: 1/22126 Static:78.3' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 11.5 79.8 TIME LEVEL 2 Mn 11.5 80 1 Min 78.8 .3 Min 11.5 80.2 2 Min 78.4 4 Min 11.5 80 3 Min 78.3 5 Min 11.5 79.8 6 Min 11.5 79.8 7 Min 11.5 79.8 8 Min 11.5 79.8 9 Min 11.5 79.8 10 Min 11.5 79.8 15 Min 11.5 79.8 20 Min 11.5 79.8 • `25 Min 13 79.8 30 Min 13. 79.9 35 Min 13 79.9 40 Min 13 79.9 • 45 Min 13 79.9 5f}Min 13 79.9 55;Min 13 80 1Hr 13 80 Total Gallons.Pumped:807.5 Gallons Punted F Mason CM Printed from Mason County DM tianguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANUA .D Report of Laboratory Analysis LABORATORY Collected by: Ackley Pump Service Matrix Drinking Water 360-508-6393 Laboratory 11): V250923-10 Sampling Address: Date Sampled:9/23/25 13:15 18308 Old Hwy 99 SW Date Received: 9/1/35 14:30 Rochester,WA 98579 Date Reported:9/25/2025 Sample ID: 1.8308 Old Hwy 99 SW Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform& E.cols by SM 9223B(IDEXX) Batch lD:9250923-10 Analyst:CB Coliform,Total Negative I 1 MPN/100 tnl., 1 9/23125 18:12 B.Coll Negative 1 1 1v1PN/100 mL 1 9/23/25 18:12 Nitrate by Hach Method 10206 Beech ID:V250923-10 Analyst.C13 Nitrate.(as N) ND 0.50 10.00 tng/L 1 9123/25 17:09 Notes: MPN.Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 09/25/2025 nia:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 09/2512025 DF:Dilution Factor 17025:2011 MCL Maximum Contaminant Level L Samples were received in acceptable condition.'rhe 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 abtut the results. 2635 Par Drat Ln SW,Suite Olvmpla WA 90 pc :'360'967.7010}testing vanguardlabotatory.com Pnnted .From fl ! +'. N� oratory.eom Printed from Mason County DM5 I of 1