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HomeMy WebLinkAboutWAT2026-00026 - WAT Application - 6/2/2026 WAT 2026-00026 415 N.6'h 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: Randall Zenonian Date: 1/16/26 Mailing Address: 101 NE Dewatto Hills Rd Phone: 262-748-9927 Parcel Number: 22317-22-90020 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more °V Building permit BLD2026-00067 connections) O Division of land: Individual water source (one connection), #of Parcels? SPL V" Well 0 Boundary line adjustment O Spring/surface water ❑ 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:\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 l Water well report(attached to application). Depth 194 ft. I Well capacity Test(attached to application) 16 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 within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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) C9 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). Reviewer's Signatures: 6/2/26 Environ. Health: �r !1' Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT Or Notice oflntentNo. WE61943 ECOLOGY Unique Ecotogy:Wellli)Tag i�Po :BNM831 Type of workz. State of Washington C■t .C orsstrtietiurr Site Well.Name(if more.tbarf one Kell): Q Decommission r 0tiginal;installation.N0t No., Water RiglitPermit/Certificate N . Prpppsel Ilse: IN Domestic O industrial O Municipal Properly Owner Name RANDALL ZENONIAN O Dewatering 0 irrigation .Q Test Well 0 Other Well StreetAddress_101 NE DEWATTO HILLS RD Construction Type:. Method: O New well; D,Atteiation a Driven ❑Jetted O CabiPPTool. City TAHUYA County_MASON L7 Deepening II 0 her O Dug L+l Air- ❑Mud Rotary 1 a7t,Parcel:Na: 223172290020' D•rmcnsroms Diamet4 of boring 6. in.,to 194 ft, .4, Was a variance approved for 7this_well?.0 yes [E]No iiepth of completed welt 19 Construction Details: Wa11 yes,what thevariancc for? Casing. Liner'Diameter From To Thickness Steel, PVC.Welded Thread_ I .O 6. in. +1_ 189 . .. Lin. lJ O O f0 Location(see instructions on page2): 'tI WWM or D EWM NW '/a-r/,of the NW %:;Section. 17 Township 23N Range. 2 -in. ❑ ( D D I q in• in. El i O 0 I p Latitude'(Example:47.12345) 47:487564 Perfnt»ti6ns, ''C3'Yes No. Type oEperfoiutor'n4ed Longitude(Example:-120.12345) -122:9704.15. No.ofperforaiions Size of perforations iii.by in- Driller's I.og/Construction.or Detommtsslau Procedure. Perforatedfrom' tl,to ft.below ground surface Tormttian:Describe by color,character,.size`of material and structure,and'thekind:and nature of the material in each layer VCnetrnted,with at least one entry for each;oliange of Screens: O Yes t7.23o li K Paoker b Depth ti, information. Use additional sheets rccessary. Manufacturers.Name' Type STANLESS Model No. Material From' :To Diameter 6 . in Slot.size l2 in.Boni 189 to 194 "ft, CLAY&.GRAVEL BROWN 0 1$0' Diameter ;in Slot size nn.from ft,.to fL GRAVEL H2O BROWN 1$0. 194 Sand/Filter pack,O'Yes it No Size otpack material.. in. :Materials,placedfrgnt It.to ft. Stirface.Sieal: ,;''Yes, ❑No To what depth? 20 ft. Material used d seal BENT0Nr rE Did.any strata contain;unpsable'water? OYes 19 No Type of water? Depth of strata Methad'6f'seating strata off Pump:'Manufactttrer's'Name GOULDS Type::,SUB HRP. 2-L Pump intake depth:18161 ft, Designed flow rate .10 gpm Water Levels:-Land<surface elevation above mean sea level. I. Stick-up of top of wtfl casing 1, f3 aboveground surface Static;ivaterlevel 153 .g;below top of well casing Date 5-18-26 Aftesiaa pressure. lbs.per square inch. Date .Artesian watei is controlled by (cap,valve,etc.) WelLTests: Wasa'pumping test'pdrfbrnied? C l,No l J Yes by whom? Yield 16 pniwitti-4'ft.drawdowrtafter 4.. hrs. Yield " fpm witli„if.drawdown;afier, hr5. Yield gpm with ,ft,drawdown after hts. .Reco'eiy data(time-:zero when pump is turned off—water level measured from wcll top to`waterleVel))' Time: Water Level Time Waterl eyel. Time WaterLevel Date of pumping test. Bailer test- gphr with-_ft,drawdown after_.hrs. Airiest gpm with stem set at: fl,for brs. Date Artesian flow- .;gpm. Ten nature oftirtater. °.F' Was'a chemical analysis triade? O Yes IS No Start Date 4.10-26 Completed Date 4-21-26 WELI.;CONSTRUCTION CERT[FICA'l[TON: I constructed and/or accept responsibility for construction ofthis well,and its compliance with all Washington well con"structrop•slap ..Materials used and`thd information repotted above are true to'my best knowledge and belief. ©'Driller 0 ee rint Name CLAYTON P177S Drilling Company COOLWATER DRILLING,INC. Signature Address.10921 NW HOLLY RD License NLf16 City,State,Zip BREMERTON WA 98312 If TRAINEE:Sponsor's LicenseNo. Contractor's .Sponsor•s Signature Registration No.COOLWD1941 QM 'bate'5-26.26 JiCY 050-1-20'(Rev 1.1/273) /You need thisiiocunrenr in-an alternate format,please call the Water Resources'Program.at .366-407-6872. Persons with hearing.loss can call 711 for Washington'.Relay Service. Persons wit/t-a speech disabilit}>can,call' 877-833-6341. L+}6�276 Twelve drs TA PoStWA 83713' " &+rte treA s c olrssi i; li 1 fJR1' MOT v 1.t I i N! Date 8amle Cotlapt Time Sample Goanty {'� j '� Ccllecied PAon Osy Year •� 1�PM > a Typeat tar: ysisrr,•(e#�ett:only one,bozj G1 t oiap:r .3 Grbup'8 titer Ga up A and Gi6up B_Systems—Prtvlde from Water Fa i ltles lnventQ.ry(WFI): systpmtaarne: � �� � �' Gontaciperson G €va,Fltone: 7', 2t S®?ttl:ce;�rlEsb{r�rntfurfr+arre�s�essarr3a'ycafeurrm�ifabtvsfae'aSachcrttaraPYafia�uics'j sA ?,.-SI FOR Ar Ô Sarnpte collectdd by(darns) 0 Spero}ccafints.where sample Special instructions or comments: ace ? rw Type::otrSarnp3�°{o�reclednlycstzebo,>€}� . ' _ tj Rou na tltstrtbutton Sample(AIP) 2.0 Repeat Sample(A4P)) art lorinated:Ves0 Ido D #from daiibu9lpn system after onset.xeurJae) Ch•lorlrie•Raslduat:Totaf;__ Frns? _ tlr se#sfaCtnry rolliine lab number: 3,ground t4tater. ule Sautes Sample �..._—�._. ,._ tlnsat'ssfactory routine ciifleetdates f' f Chkanna€ed.Ye No D Triggered(Aft-?) Chlorine Residaat:Total Free. ©1§ssestr nt(MP) 4.844 sce or GWI Raw Sauna WaterSample(Enumeration) co! 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