HomeMy WebLinkAboutWAT2026-00119- WATER ADEQUACY - WAT Application - 11/13/2025 WAT 2026-00119
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,,CommunityHealth 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: Ben Mangeng Date: 6/5/2026
Mailing Address: 5831 SE Arcadia R, Shelton, WA 98584 Phone: 775-340-8651
Parcel Number: 22030-10-94092
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ® Building permit BLD2026-00427
connections) ❑ Division of land: Shop with recreational area
l Individual water source(one connection), #of Parcels? SPL
lI Well ❑ Boundary line adjustment
O Spring/surface water O 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)
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
IN Water well report(attached to application). Depth 188 ft.
l Well capacity Test(attached to application)_17 gpm N/A 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.masn.wa.us/planning 14 X 15_16_22_
Water use or limitation recorded................................... N/A_____N/A Yes_X_(Short Plat)_
Well Drilled ............................................................... Date 11/13/2025
Individual Spring/Surface Water
O WDOE permit(attach to application)
O Method of disinfection
O 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)
l 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 6.68.04O-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:
6/11/26
Environs Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATERINE1.L REPORT DEPAR MEN1 orNotice or intent No. WE61520
ECOLOGY Unique,F.cologvWellIDTag.No: BPN 084
type pr Work: arczt€trzcitin ton
U Canstructimt Site Well Name(if more thanone well):
O Decommission t Original installation Nt)1 No. Water Right PcnuitiCertificate No.
Proposed tine: i.0IDomestic C:industrial 'Municitrtl Property OwttcrName Benjamin Mancieng
O I)Cwatctinp 0 Irrigtian 'Test Well 0 Onto
Well Street Address.0 SE Arcadia Rd
Construction Tpe: Method:
C'7 iic%v u2ll i==Alteration `.t)riticn C'Jened ,C Cable'toul City Shelton County_Mason
:a`-1 Dccpcninp 0.Other =?Dog I$ Air- L."�tual•ftotary Tax Parcel No. 220301094092
Dhnensiotrs:'Diamcfcx af(xtri'g 191 8• Was a variance approved fordhis well' D.Yes CD No
Depth ufcompleted well 188 IL
Construction Detmta
W ill if yes,what was the variance for?
(.Using Liner Diameter Viii tt In 1ltickness Steel PVt,:\Welded 1 bread
C•7 j J G in. 1112 .25. in. ] ( J J i O Location(see instructions.on page 2): S WWsti2 or D EWM
U I LI i .___ f4 t4 ortlie NW 'V Section 20 :Towvnslup 20!1 Ran _L.
1 ID in. itt Latitude(Example.:47.12345) 47.19795
Longitude(Example:-120.12345) -122.97835
Perforations: 9 Yes =No Type of perforator used
Driller's LoglConstruction or Decommission Procedure
Ao.orperfbe itions Site of perromtiuns in lay in• Formation,Dt rtbe by color character,sire ofuratcrial and stiuci ur. and tL1 kind nutPat1'prated Irom ft to. it.t+elow prrtund 4orfiica uaturc oCthe tnalurfat in each layer penetrated,with at least title entry foe can t change of
Screens: j!1 Yes El No l: IC-Packer Depth..1L.p, information,'Use atlditiatctl slicers if nccessary.
fannfsctumt s Name IOHNSON _.__—___.___. Material From To
Type STAINLESS. Model No.
Diameter 5' in: Slot site 16 in.from 83 Ii.to 88 i, CLAY LOAM BROWN D 2
Diameter_ in. Skit sue__ in.from_ft.to Ii. CLAY BROWN 2 .30
CLAY BROWN 30 45
Sind/Filler park-0,Yc-s -No S1S of pack material_in. BLUE CLAY 45 50
Materials placed ffum ft.to-Is. BROWN SAND 50 90
Sorracd Seal: K Yes O No 'ro.wtat depth? 19 .It. GRAY CLAY .90 1,60
Material uS'cd in seal 3/8 BENTONITE CHIP
bid any strata coatiittunuaable water? D Yes El No CLAY RED 160 180
Type otwatcr.? Dcptli ofstrata CLAY GRAVEL SAND WS 180 191
Method of c'aling strata off
Pump tianufacmrer's Name Type:
II:P.- Pump intake depth: 4i. Designed flow rate: ppm
Water Levels: Laud-surface elevation alcove ntc.m sea level ft.
Stick-up of top of well casing: 1`•5 IL attawc ground surface
StUtic seater level. 147 It.below top clwell casing gate 11/13/2025
Artesian pressure ills.persyaare inch Dite
Artesian iwater Is ioittrulledb' (cap,valve,etc.)
WYell'Testss
toes a ptutsping test pertbrmed? NO O Yes c} by wltontl.
Yield pot w•iilt_it.drtwdown after his.
Vi41d„_Wm with_fl.,draw•down aticr, hr.
Yield ptm with—ft.drawduwn after- Itr_a.
Recovery data'(time=fro when pump is turned otT—water level measured fivrn well
top to water larei)-
'lime Water Level Time Water Level Time Water Level
Date ofpumping test
flatter test pim iwidi—IL dmwdown a Ilcr_tics.
.•A r test 17 gpm with stein set at j88 Ii.fur 6 his. 17a 11/13/2025
Apcsian flow gpm
1'afnpcmture of water F 1Vus a cln mica!attar}pis tttadc? G Yes (I Nu Start Date 11/0912025 Completed Rate 1111312025
WELL CONSTRUCTION CERTIFICATION: 1 constntcled and/or ai:celit.rttponsibility for consttuctiou of this well,and its,compliance with all{It ashingtgn well
coast uction'standards.Materials used and the information reported above are true to my best knowledge and belief.
0 Driller D Ttin 0 PE—Print Name ROBERT LAYMON, Drilling Company ADVANCED DRILLING LLC
Signature i '7 Address 11530 SCHOOL LANDRD SW
Isicense Vin•2588 ('icy.State Zip ROCHESTER WA,98579
lFTRAlNl;f--:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ADVANDLS0SDL Date 11114120.25
ECY 050-i?0(Rev QStl,ttl y}'err rat Fd thLs floe urrrcut in an alter'rraw lirnntir,please tall the tl ater Ravortrccs Pro rant us 360.4(17-6572.
Persons with!fearing lose can call 7//for Il ttsNitV1 on//dell'Semler. Persons tt•irlr asprrc/r dis4bifi t'Con call 87`833-15,141.
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 985O6
360 867-2631
TAURSDDN COUNTY
_ COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
' J Collected �y
Month Day Year 8+ " : Phi Ir y ff
Type of Water System(check only one box) Private Household
Group A ❑Group B ❑Other.__ _ . - {
Group A and Group B Syste s—Provide froj Water Facilities Inventory(WFI):
System Name:
Contact Person: ,•
Day Phone:07 7ç) jO 1 Cell Phone:(mac, ) `1O
E•mail:� g {� 1AI>[ k Eve.Phone:( ) 1,
Sendresults to:(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name),
Specific location or address where sample c6lecte Special instructions or comments:
Type of Sample(must check only one box of#1 through#4 listed below)
1. outine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated Yes. No ❑Distribution System
Chlorine Residual:Total_Free_ Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total—Free_
❑E.coli—GWR(NP)
o Fecal—Surface.owl,springs(numeration) Unsatisfactory routine lab number'.
Filtered:Yes
❑Assessment Monitoring(NP)
Unsatisfactory routine collect date:
❑Other 1 1
S ,
Sample`Collected for information Only
Investigative Construction/Repairs` Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑Ecoli present ❑.E.coli absent No oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coti 1100ml.
Fecal Coliform /100ml Enterococci /100 ml.
Method Code:)J SM 9223B ❑SM 9222D Date and Time Received.
❑SM 9215E O Enteiblert0 2L (1'c)i
Date and Time Analyzed: e -U Date Reported:
Sample Number(DOH number plus five digits) Lab Use Only:
DOH Porn#331.319(revised 11123)
A .