The URL can be used to link to this page

Home My WebLink AboutWAT2026-00110- WATER ADEQUACY - WAT Application - 5/22/2026 WAT 2026-00110 MA , NCOUNTY415,WA 8584 Shelton, 98584 4 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 requlred:attachments for review. 4. An,approved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name of Applicant: / J Date: / ? /24 Mailing Address: y5 O 0 Cl>t\/Lr d'� Phone: 3 o'P7V - ?✓Fl� Parcel Number: 5a OD 7 7 t,,,0 O Type of Water System Reason for Application ❑ Public/Community Water System (2 or more lwiuilding permit BLD2026-00469 connections) O Division of land: ®' Individual water source(one connection), #of Parcels? SPL EY Well ❑ Boundary line adjustment O Spring/surface water O 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 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 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 - i Group B Water Systems O Satisfactory bacteriological test within last year(attach to application). Individual Water Well 5 Water well report(attached to application). Depth 119 ft. I Well capacity Test(attached to application) 4-13 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. El Satisfactory bacteriological test within last year(attach to application). 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) �1 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.requlrements 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.. Q Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of Its Intended use for the following. I reason(s): Reviewer's Signatures: Environ. Health: Date 6/22/26 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 U@F'AH MLNI C F: WA R WELL RREPS R"T (� rlotlei orintemNo Wrba377 ECOLOGY Y T)ntituft}Icology WoIi Zp Tn6 No. BQC404 xy)ia of'Wifrk: tilale o.LWpshington . CI: eonstrnoiiou Site Weli.Nsnle(if snore than one well): Ca:Deconuuisston Utigin ilinsinllntion NO!No. Water Right Permit/Certificate No. 1'rojiascii:T1se QDontesliu C Indiislridl 0 Almiicipol ProperlyOwnyrNatne.Leah Coleman U I iewti1efing Q;1rngniidit 0 lest W.ilfl 0 01lfer_ Weil StreclAddross:.:B41 WwinchesterWay onstrucdon'Pype: Mofliodt City Shmifoh. [l 4iii ell: 'El Alteration p't�riyen C dkttul .E1 L abieloel County Mason El Decpynlug iJ 0,t4t ©1]ng. 1)Air- C1 MuifiRiihtly `faat.Parcel No 32007 7a-:00060 iliptensirrns I)ialnvier.offivritl8 6 its td 119>. R: VJnsn variaiico approved for this Well? EJ Yes C'I No Dopih ofcomploted svi IL 110 IL CocsirticttotiJli loafer II yes,what was the vtlriaiiaofbr7 Casing Liper Dinmoler .from To 1ltiokness Steel. gVC.Wbldcd Threed L] I 09 .An. ii 25, in. :6 I 0 lftl I0 Location(see insIrgGtiona osi"page 2); I3 WWM nrU JM51 D Ll in. in. •El .D CI I LJ /r , r. in: ln, p 1 p q i 11 o-/apftile SW ! 8witin 7 Township._221L Range 6W I. t)tuda Exata te.47;12145) 47.231051 N Cl I :Cl in —. T_. in, '0 J :0 Cl .( CI { p Isongftude( calitple 12!712345) 423 33009W W •YCrfartftiottst 0•Yes IStil4 fypogirort?Intlor utcd .. _. . No.of)terforlilioiis S1�oorpar'orntioinr in'by tn llrilldt's ng/CoristPticfian oe Aceoanaiisslun I'roc6(lure PafdratGd{bot ff,_to�:It.belowtttoimdStlrfice peNinse iDcScnbdbycolarabAteelersizeofnistenilaud'sliltchtrawtui'iokiildrind; �r nAiiirantllic tnstoniti to eppf>Myer tiohvicptoa;wilts ill Inset one onfr3 tbrauo t eleuige of :Sct«eusr l-l'Yes i No' El:K=Wlakdr n$iilt r ft• inibreisition..Us itdflifton I sheets iftlgCC86nl}. Ivlatifncturir'sNama Mptcrlti[. i+rom ko ,.. Modell No. I)itivaatar_� Slotsizd_;iin from �_It,to_ Brown f3rown Sltt sand and ravel 0 .5 'Dinmelor SI'stsize.. ui.':front ftto R. Silty send travel cobbles`... 6 8 rows silly sand and ravel. 8"... 16' $iijii{/ltiltor.plyk I7 Yes: IS No . Size ofliuok materiiil^in. I4latCrinfs ptnood frntSi_11 ta_!k sill S ffd, i cAb 1 t3 16 St rfnca 3chl'r.(91 YEs- Nc , . 511t seideifid gravel nnlsf .... 14...... 4i; To ivhatdgpih?B n Ntiltonptuged glees! BI iitdrilfe.Ghlps Kaddish 4roWn silty sand $:ar' ravel 46. 60. Rid atiludn:conlan:itinisHl2la tvAlvr2 c)Ycs 1 No Brown siltboutld 81ld rte ravel tastes 60 8t) typoofwetarP I1i.pih,ofsttatu Silty ccarsesaDdend Cll vel water 80 to Method ofo niniigsh am cart Coarse sand and round gravel,water• 110 119 Ittul?:.tvTnniinouitcr's\i me • Ypet. .. . ii P Pi nip iafako depth.. ..''Il. iDbsisnudflow tots-spin . .,. %Pater l eve)si Land siirfe o cliiyi tlort abnva inssnsFn level 11: Sf cl up of tap of Well cnoultt It abttve greeted sntface '$tdtip wpter tevei. . _7„ .1t,below"tpp:orwellawing Date 117/25 Aitognnpiessure lbe perscjunra-inch 13itte_ Arlgstiueivnter is controltod.by. __;.__(pap;:vtttvo;.ed): 'W/no n:piunlsin.jt tau Parfnrnted? L�1:.Nit El:Pus by.wliOin4 Yield 81intwith-_____ti,drawdowiaitaer _ firs. iota. gpiliwitlt_R.tinnydoivuitllor_firs. Yield._,g(?nt with_Il,drnwdowir after_firs. Rcc;onry lain:(limo=zero'w)idninmrspishirOdoff—ivulor.leyGdntoasivedfconi,well tap:toyvtitdrlo'ol) 'rime lvtitor Level 'fln;n Wutor Level Time Wete.r tsovol S. .. AAiv>Ofpumpiiig lost Bailor test gput with—ft.drnwdown After___'Irrs. Ail last I5 gpiulvilh slant List.ti 10Q h.for 1 tiro r Ditto'4117125 _ Artesian flow :spilt Temperntitret>.fvetar r�3 °.t Wtis.n chomicnl mtalysis nmde? :D Yes No Stprt IJatt h117L25 Eompleti d Dote. 4717125_ WELL CONSTRl7CTION-GJItTJFlcA'rt0N: I constructed:audlor.apcoptresponsibility for construction of this well,and its compliance with all Withington'welt eabstntction standards..Materialsused sold the infbnnutit)n re}iorted abo'e"nfe titie to Iey`.best.kuotvledge-shad belief. Ii]tDriller•Li Trainee.O:PE—Print-N • fVJohnson ISr tiling CoinpanyAroadle Eli illing Inc • Signature r" Address:PO'Box 1790 I icense:No.3441. . City State Zjp Shelton WA 98484. IF TRA1113F:Sponsor 5.Lieense No.. Cbnfraetor's ^Sponsor's Signature. Registration.Nn:'ARGADDIb98K1 -Wte 411.7/25 ECY 050cl-2.0(Rev.09/18) jl'Yarrr'ieed 11i( r/citwhmnnt In an nher•npl.'e formal.pleirse call the Water Resources Pritgi•arb at 360-407-0'872: Persons u'(dth hearinsg'oss-can call'/1/for War?ningloii Belay Serrlce'. persons with tt speech tlisetbtHty.can pa11877,ifi33i 41 1. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Leah Coleman Well Tag#: BQC104 Site Address: 641 W Winchester Way,Shelton Depth: 119' Date of Test: 4121125 Static: 79.5' Pump Set: 100' TIME GPM LEVEL RECOVERY I Min 4 79.8 TIME LEVEL 2 Min 4 79.85 1 Min 79.6 3 Min 4 79.85 2 Min 79.6 4 Min 4 79.85 3 Min 79.6 5 Min 7 79.85 6 Min 7 80.1 7 Min 7 80.1 8 Min 7 80.1 9 Min 7 80.1 10 Min 13 80.1 15 Min 13 80.6 20 Min 13 80.6 25 Min 13 80.6 30 Min 13 80.6 35 Mln 13 80.6 40 Min 13 80.6 45 Min 13 80.6 50 Min 13 80.6 55 Min 13 80.6 1 Hr 13 80.6 1 Hr 10 Min 13 80.6 Total Gallons Pumped: 831 7hurs4n County. . nSrlC�rtri>enl laealt} 1iUy Rd NE Vii-Qlympla,WA 9.850.6• : �kiz3R N*ovr,rx 3 8 7 63i. • CQL1FO} MBACTERIA ANALYSIS DataSah}ple-Collacfed ]theSamp(e County Golleatetl � . Month ... 'ife Ye$r Type of Watt[System:(ehck otly6ti bok) ro Pfivate�FCousaFfola : D Orpup A O group B Lj Other________ GrnapAan :CmupB.$yatemS Ptovldefroi 'WaterFaoilttiesfrttrenfory(NIFJ):; Sy§tem Name : � r�tgal herprt `p Oay 6o>le Ge(thorie ( E rllajr Eve Phone ) $ed rE361(Its ( fJ[f tul(ri e address-end zip code or anreli pddrpss} } S AM?1.E JNi 0RMAT1 N.: 5antp)e.collectedly(name) S ecjflc tot atoh of adtlress wliete Sample ocll(ealed Secla(Iristruo)ions of 4mments .. L { Yij.�. te . 1 pe 6f Sanrtpli3(iii t7shck onljrone box 4f M}hraugh }I1;ted below) i O Rotr ine biStrlbutlon Saitip(p 2,Repeal$ nlple(effat tansat;rotttlne) Chlor►(ta}ed Yes NQ__. ( I Ofstd(3pilon ystetrt hlarinelesfdual7dtfi( ree CItlgnrtatedtYes 3„ftaPrWatei Sure------ d,.. Chlorine?:Resldubl lota( Free f j Fqe l turmce GWI p no n nuntoranon) Uttattdfaotoryro itine lab nun1 er;.. EllteredrYea„�. ,No . o issessment Nibnitoring(All?) ::tunsatbfaotory routine cofiddt data.• Gomel c l rinformatlanonly I- ItivesfJlatfve Constritotiop/Repairs Other: LAB USE ONLY DINKINGWA1ER.RE8ULTS LA)3 U5=ANI Y' E Uttsatfsfaatofy Total CoJlfonrr Present and Sdttsiaator t t I cllpresent Q gdlt 65ont N Califormtteteitetl 12e 1bdetnei t a1pj R qult`ed: ©sample too old(3(1 houtd) Q INTO [7. _ • Sac feitDriitgt exults TntalC11(arm Jitloml. E•coll _..J-1OOm1. .. .? Fecal Collfot dbi}rnl Eitterocoech 1100 nil, Method Code C SM5222D Dais-end Time Recerved ' s- ti SIv1 21 � - •� r� r 0�nterole !? z Dale endTJmeMalyzad, ry. Date:Reported ,a amdra Nunivec(oo _number i4g we d g4).: • Ldo Use hly. Q 8 0 p(ifotni 1.319 yawli t5