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HomeMy WebLinkAboutWAT2026-00107 - WAT Application - 6/15/2026 WAT 2026-D0107 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 accompahy this application. Part 1: Applicant/ Parcel Identification Name on Applicant: Joe Ruffino Date: 05/12/2026 Mailing Address: P.O. BOX 1731 Allyn WA 98524 Phone: 206-383-3958 Parcel Number: 22112-78-00150 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit BLD2026-00460 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL E(Well ❑ Boundary line adjustment O Spring/surface water ❑ 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) ❑ 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. 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 1/25/2018 Individual Water Well I�Water well report(attached to application). Depth_201 ft. Well capacity Test(attached to application) 12_gpm >400 qpd 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://gis.co.mason.wa.us/planning 14_15_16_22_ Water use or limitation recorded................................... N/A_____N/A Yes Well Drilled ............................................................... Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ 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) $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 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. 0 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: 6/15/26 Environ. Health: Date CSD Director: Date 2 oft WATER WELL REPORT t DEPARTMENT OF Notice of Intent No, WE58669 ECOLOGY Unique Ecology Welt ID Tag No. BNM 836. Type ofWork. State'of Washington IE•Construction Site Well Name(if more than one well): ❑'Deconmiission Otigrtal installatioaNOI No. Water RightPenmit/Gertifrcate No. Proposed Use (l Domestic O industrial Q Municipal Property Owner Name Joe Ruffino O Dewatering ❑rlrngation, 0 Test Well ❑Other Well Street Address 451 E Buckboard Dr Construction Type:° Method: ©New well. Q Alteration ❑Driven ❑Jcttr:d Q Cable Tool city Allyn County Mason O Deepening ❑:'0ther 0 Dug 0 Air El Mud Rotary 'Tax Parcel No. 221127800150 'Dimensions:Diameter of boring 6 in.,to 201 ft• 201, Was a variance approved for this well. ❑Yes D No DepEho£completed well' ft Construction Details: Wall If yes what-was the variance for? Casing Liner:Diameter From To Thickness Steel PVC Welded Thread © 0 6, in: tl 196 1l4 in. (l I 0 jl L Location,(see inshuctions on page 2): ❑'W WM;or O EWM ❑' I ❑ in in. 0 ) ❑ (I j ❑ SWL%'V4 of the .N E' % Section 12 . Township 21 N Range ❑ j D in in. ❑ I EJ Q' I ❑ ❑: j :O ,in in. d I 'Cf O I p Latitude(Example;47.12345)47-325085 Longitude(Example:-120.12345) -122-872321 Perforations: O Yes, ,p No Type of perforator used No.ofperfordtions Size,ofperforatione in by_in Dnller's Log/Construction or.Decommission Procedure Perforated from T ft.to_it below ground surface Formation:Describe by color,character,size of material and structure,and tLe lgndand nature of the material in each layer penetrated,with at least one entry for each change of Screens: ©Yes 0 No l K-Packer c :Depot 193 ft. information. Use additional sheets if necessary. Manufactumr'sName Johnson Type stainless Model No. Material Fzotn To Diameter 5 in. slotsize 12 in:from 196 ;0..to 201 ft Brown clay&sand 0 55. Diameter in. Slot size in.from tt.to ft: Sand wet sulfur smell ;55',, 130 Blue clay 130 138 Sandifer pack:.O`Yes O No Size of pack materiat_in. Materialsplac tiom. $to ft Sand Wet-sulfur smell 138 . 148 • Blue day 148 155 Surface seal Ll Yes 'O No To what depth? 18 & ear own• b5. 165 Material used inseal bentonite Did any strata coni:un unusabiewater? ❑Yes ❑No Blue sand with water 165 170 Type of water? Depth of strata Brown gravel with water 170 201; Method of sealing,strata'off Pumpt Manufacturer'sName goulds Type: sub H.P. 1` Pump intake depth:180 g• Designed flow•rate:'12 gpm Water Levels:Land-surface elevation above-mean:sea level ft Stick-up'oftop ofwell casing_ .ft above ground surface Static waterlevel 132` ft below top of well casing Date, Artesian pressure_ ._abs.,per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests t 'Was a pumpmgtest performed? 0 No: ❑'Yes r by whom?` Yield_gpmwith_it;drawdownafter lets Yield gpm with IL drawdown after• his. ... • ` Yield gpm with fi.drawdown after hrs. Recovery data(time,=zero when pump is turned off—water level measured from well top to water level). Time WaterLcvcl Time Water Level Time Water Level Date ofpumping test Bailer test 12 gpm with ft deawdown after 1 In. Air test_gpm with stem setat.ft for`hrs. •Date Artesian flow_gPn?� Ta2 - m eratere"of water F Was a chemical analysts made? ❑Yes O No, Start Date 2-19-25 Completed Date 2 25-25 WELL.CONSTRUCTION CERTIFICATION•,I'constructed'and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the infotmatioifreported,above are true to my-best knowledge-and belief. O Dsiller OT ee DPPE—Print Name Clayton Pitts Drilling Company Davis Driilirig 5i lure Address 340.NE Davis Farm Rd LtcenseNo City State Zip Belfair,WA 98528 IF TRAINEE:.Sponsor's-Lieense No. Contractor's. Sponsor's Signature RegistrationNo.DAUtSD111 OA Date MARCH 2025 ECY.050 l-20'(Rev 08/1;9)Ifyou need this documentin an alternate format please call the if,'aterResotr'rces-P"rograni ar 360-407687 Persons wifh tearing loss can call 711 for 33'ashingtnn Relay Service. Persons with a sjieech disuhility cigr call 877-,433-6341. 26276 Twelve t Trees LnNW Ste.C SJECTRA Laboratories. K,csap, Poulsbo,WA 98370 Wkrrt ' 'irhrtcm marina (360)779-5141, GOUFORM'BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Month Day Yesr _O PM Type of Water System(check only one box) p ❑Group A ❑Group B [g Other P�!V4 r�',„ Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: � r c dL.!'T'1 i-'J Contact Person: Zd e- t f'r'N O Day Phone:a.06 ' 33 - 31 S Ce l Phone:nog.' 3 y .Email:6( LL .oWDO&6 ZC- pL.Coi Send results lo hull e,address and _ `oe. f17N ' Q oY 1 7 3L c. . av a SAMPLE INFORMATION Sample collected by(name): R To c Specific location where sample collected: Special instructions or comments: ��zsSI&At TaNlz Type of Sample'(chectc only one box)' 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(A/P) Chlorinated:Yes ❑ No❑ (from distribution system after unsat routine) Unsatisfactory routine lab number: Chlorine Residual:Total_Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: Chlorinated:Yes No ❑Triggered(A(P) Chlorine Residual:Total_Free_ ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) i ❑ E.coil ❑Fecal Fissred Yes_No_ 5, mple Collected for Information Only: ❑PAvab Residence ®Constn Ibn1 Repairs LAB USE ONLY DRINKING WATER RESULTS ,..CAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.cofl present ❑E.cofy absent Bacterial Density Results:Total Coliform mpn/100ml.Eco6 mpn110Dmt. Fecal Coliform_ w�,cfu1100ml. HPC,, .,__cfullml. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ Daleftime !V Lab Reference Number Receipt Temp C°: Method Code: 7236 T-COUNTISM9222D 'Date In: Date Out lies rapod is esredsoldy hsr U useartte peI%nc mmpemy to it 1 f/+j LJ' etnrn ltls aditswd.Arf—wpybV a ftdmre 0.Nan by to .J 1 f SiJ,/ `�*7J eaor,pame nobly M sender immedetdl tl36 9�114f aa�pd destrof thisr a tp,—pr. DOH Lab-Sample# /♦^^-g, ilesere%tsrdstec1y b t eiems tesoed andtosmr s)w .'. o4o- 7 `{, F romred by tekbaalarY.This apot hal nd berepmduoad ezospl t✓ t in 51!.witltodpriaretyraw miser appradhy fpemnLdadaiae DOH F—M31-319{eeaetva 0%117) t i Jf .....