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HomeMy WebLinkAboutWAT2026-00094 - WAT Application - 6/4/2026 OI WAT 2026-00094 MASON COUNTY COMMUNITY SERVICES Building,Planning.Environmental Health,Community Health 415 N 6th 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 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: \')mi1 2etit.S 1C Date: `-+ .2o2- , Mailing Address: Lbl N•Hc�s ikta�k Chc11.ltcl,'WPv`IbSSPhone: Parcel Number: c' cc ID 1<or1 OF SQL2oZç.00aa`t") Type of Water System / Reason for Application Public/Community Water System (2 or more El Building permit connections) 0 Division of land: Xl Individual water source (one connection), #of Parcels? SPL 0/Well O Boundary line adjustment O 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. Not an approved two party well Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Na Water System: kiv Water Facility ntory(WFI)Number: — -4-- (write"none"for tw rty) I am the manager of this water sys The water system een approved for 2- services. There are.presently 0 connectio 'n use is will be the 1 connection. O I am the manager of this system.This co c ion w e to upgrade or change the use of an existing connection on this system(i.e.: re ional to full time). e indicate on the following line the nature of this change: This water system ' e and willing to provide water to this (these)conn ' n(s)without exceeding the limits of water system or any limits set'y state and local`regulation. Si ure of Water System Manager 7 '1,✓l .t ' Date �"3°'•Z This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well ll Water well report(attached to application). Depth 69 ft. ® Well capacity Test(attached to application) 100 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 http://qis.co.maSOfl.Wa.uS/lDlaflflin1 14_15 16 22_ Water use or limitation recorded................................... 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) ® 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. D 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 6/4/26 CSD Director: Date 2 of 2 K�.:GEUVED APR 01► 2025 WATER WELL REPORT k' a r:t'A n 1 M E N l or Notice of intent No. WE59046 ECOLOGY Unique Ecology Well II)Tag No. BPN072 o f 1'::;•, i.• r_�9 1'ypc of Wnrh: SWtc at ttatibington Cl Couatruclian Site Well Name(if more that%one well): © Decommission Original installation Ntll No. Witter Right PerniliCcrlilicate No. Proposed Use: m Domestic ;Industrial ;Municipal Property Owner Name DAHL PROPERTIES INC El Dewotering Irrigation =Test Well C Other Well Street Addir.+s 0 HIGHLAND RD ._ Construcllmt Type: Method: Cit SHELTON County MASON L!J New well 2 Alter Lion Driven C Celled ^Cublc'Iirol y H Deepening _1 Other :Dug t!'.Air- :mud-Rotary Tax Parcel No. 52024-13-50010 parent parcel # _._. ____ IMunenulnac: Diameter of buriug G in..lo 69 0. Was a variance,approved lbr this well? 7 Yes IJ No Depth ufcomplcicd well 6f1 0. If yes,what was the variance for? Construction 1)etalls: Wall Casing Litter Diameter film To 111iekncss Steel PVCtVelded Ilacad pp I ❑ 6 iii. ti 4_ fib .25 in. C1 ► `1 m I J Location(see instructions on page 2): C)WWM or 0 EWM LI I U hi. — iti. LJ I -_I i_I I —1 NE r/-'h of the SW ;ScctionL Townsl p.2L Range ❑ I ❑ i°' --- --— in. ❑ 1 ❑ ❑ I ] Latitude(Example:'17.12345) 4-!.21047 ❑ I ❑ ia' in, O ❑ ❑ I ❑ Longintde(Example:-120.12315) - 123.25223 Pcrfuratluus: ❑Yes N Nu 't'ype of perforator used Driller's LogIConstruct(mt or Decoouuisstmt l'voccdure No.ofperfmnlioas Sizo of perforations Iii•by in. Formation:Describe by color.character,size ofnrulcrial and stnIetun:.and the kind and Perforated horn q.to Ft.below ground surfmco nature of ilia material in cacti layer penetrated.with at least one entry fur each change of 63.5 nformation. Use additional sheets ifnccessnry. Screens: !�;Yes LJ No fit K-Palter �' Depth _Ii. i Mnmutiicturer's Name JOHNSON Material From To ;p Type STAINLESS Model No. SANDY LOAM GRAVEL 0 2 E Dialuctcr 5 in. Slut size 1 m Ei 0 iii.rum A.to 69 0. CLAY LOAM 2 6 !)innrcicr in. Sim size in.Ono-n.In 11. 6 26 o CLAY GRAVEL BROWN Sand/Filter pack:C Yes s7 NO Size at'pack material GRAVEL CLAY BROWN 26 50 >- Materials placed front It.to 11. BROWN SAND 60 66 d E Surface Seal: Yes ❑No To What depth? 19 0. GRAVEL SAND WB 55 69 C. Material used in seal 3/8 f3ENTONITE CHIP CDill any strata couture unusable water? O Yes ©No L Type ofwater? Deptli ol'stratn ._ t7 Method of scaling straht off Punup: manufacturer's Mimic Type: II.P. Pump intake depth:--ft. Designed flow role: Spin Wnter Levels: Laud-surfiree elevation above ntenn sea level_.fl. Stick-up of lop of well casing i'1.5 0.above ground surface Static water h:%vt 32 n.below lap 0F welt cusiug Date 03115!2025 Artesian pressure hits,per square inch Date Aneslan water is comrollcd by (cup,wlive,etc.) \Nell Tests: Was it pumping test performed:' 3)No O Yes t- by whoa. Yield Spin will, 0.drawduwn alcr—hts. Yield %rpm with_ft.dmwdown alter—lirr. Yield gpm with____ft.drawdown niter—hn. Recovery chain(time—zero when pump is turned o0'—water level utciisurcd from wall top to water level) 1'hme Witter Level Tine Water Lerrol Thue Wiuler t.cvel 0 U — u i- Date of pmnpiag lent C Bailer test glint Willi^0.dmu•down alter_Itrs. Ale lest 100 gpm n irh atom set at B4 n.for 3 1115. Date 3115!2025 Artesian flow Spit 1'empcmture of water "F Was it obcniictd analysis made? G Yes M No Start Dale 03/14/2025 Completed Dale 03/15/2025 3 WILL CONSTRUCTION CERTIFICATION: 1 constructed amL'or accept responsibility for eonsttuctiou of this well.and its compliance Willi all Washington well c coustnlclion standards.Millennia used and tile iufonnntion reported above are true to my best knowledge and belief. 19 Driller❑Trnine'❑PE—PrintNauie ROBERT LAYMON Drilling Company ADVANCED DRILLING LLC Sigitilitn'e �� Address 11530 SCHOOL LAND RD SW License No. 2588 City.State Zip ROCHESTER WA 98579 II''l'ltAINL'R:Sponsor's license No. Cuntntetor's Sponsor's Signature Rcgistntion No.ADVANDL804DL Dale 03/1712025 EC\'050-I-20(Rev(18,19)ll}rou nerd this doraarent In an aUrrnate liri'lnal,please rail the Water Rayourees Program at 3611.407-6S72. Persons wkh hearing lorry can tall 711.Pn'Il ashinglon Hell,'Serrkce. 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