The URL can be used to link to this page

Home My WebLink AboutWAT2026-00154 - WAT Application - 7/22/2026 WAT 2026-00-154 MASON COUNTY 415, Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Serullc s. 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 7/22/2026 Name of Applicant: KRONQUIST STACEY LEE Date: Mailing Address: P O BOX 641 ALLYN, WA 98524 Phone: 360.204.9199 Parcel Number: 122294400041 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 9l Building permit BLD2026-00145 connections) ❑ Division of land: garage wl plumbing W Individual water source(one connection), #of Parcels? SPL ® Well O Boundary line adjustment O Spring/surface water O 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) 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. 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 ® Water well report(attached to application). Depth 64 ft. l Well capacity Test(attached to application) 10 gpm N/A for garage 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 ❑ 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) gi„ 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; Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s)'. Reviewer's Signatures: 7/22/2026 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 oft O Please print, sign and return to the Department of Ecology Water Well Report Current - Notice of Intent No. W 1•90Qii2 Original —Ecology, lit copy—owner,2nd copy—driller iii:ii�i�i`�ii O E c 0 t 0 c r Unique Ecology Well ID Tag No. ALIB 238 CL Construction/Decommission Construction Water Right Permit No. Decommission ORIGINAL INSTALLATION Notice Property Owner Name Stacey q1 i s ii 2 .,j ofIntent Number Well Street Address 231 E Nelson Rd. PROPOSED USE: Domestic ❑ Industrial ❑ Municipal City(r pem1 ew County lrsrl y ❑DeWater ❑Irrigation ❑Test Well ❑Other t Location el �l/4-1/4 l/4 Sec__�9Twn R,W EoWM Ecircic TYPE OF WORK: Owner's number of well(if more than one) WWM®one = New well O Reconditioned Method:❑Dug ❑ Bored ❑ Driven Lat/Long(s,t,r Lat Deg Lat Miji/Sec O Deepened l,R Cable ❑Rotary ❑Jetted r_ DIMENSIONS: Diameter of well inches,drilled 64 ft. still REQUIRED ) Long Deg Long Min/See O Depth of completed well 64 ft. CONSTRUCTION DETAILS Tax Parcel No. 12229-44-00041 2229-44-00041 Cu _ Casing Welded 6 Diam.from +1_ft.to 5_ft. E Installed: Liner installed " Diam.from ft.to ft• -CONSTRUCTION OR DECOMMISSION PROCEDURE li.. Threaded Diam.from ft.to fl. O Formation: Describe by zolor,character,size of material and structure,and the kind and 0 Perforations: ❑Yes No nature of the material in each stratum penetrated,with at least one entry for each change of C -- Type of perforator used •information indicate all water encountered. (USE ADDITIONAL SHEETS IF NECESSARY.) SIZE of perfs in.by_in.and no.of perfs_from_ft.to_fl. MATERIAL FROM TO Screens: LAYes ❑No lkK-Pac Location 57 4.1 Manufacturer's Name O Type sta 7 nl ess Model No. Diam. __Slot size1pfrom�9 ft.to 64 ft. till 3 19 Diam, Slot size from ft.to ft. Brown Cu CraveUFilter packed:❑Yes 3fl No ❑Size of gravel/sand Materials placed from ft.to ft. Brownclay_&_gravel 19 24 R Surface Seal:: Yes No To what depth? _ ® ❑N ft. Material used in seal— Betotute -Brown_clay_&_sand .24 28 Did any strata contain unusable water? ❑Yes No Type of water? Depth of strata Fl_brown_sard_with_water 28 —64 Method of sealing strata off A 4.1 PUMP: Manufacturer's Name H.P. Type: L Cu WATER LEVELS: Land-surface elevation above mean sea level ft• Cu L Static level 20 ft.below top of well Dale Artesian pressure lbs.per square inch Date i—, Artesian water is controlled by O (cap,valve,etc. Z WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump test made?5a Yes ❑No If yes,by whom? Yield: gal./min.with ft.drawdown after hrs. O Yield:- gal./min.with ft.drawdown after hrs. Yield: ealJmin.with ft.drawdown after hrs. Recovery data(time taken as zero when pump turned o//)(water level measured from well top to water level) O Time Water Level Time Water Level Time Water Level 6 V W Date of test OBailer test_ 1 0 galJmin.with 35 ft.dmwdown after _hrs. ' ti gt n State Airtest galJmin.with stem set at ft.for hrs. y r Artesian flow e.p.m. Date E Temperature of water Was a chemical analysis made? ❑Yes 2 No Start Date 713/05 Completed Date I- CU WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all CL Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. O Driller/Engineer/Trainee Name(Print), /� Drilling CompanyDavis Drilling a Driller/Engineedfrainee Signature L �_Q/y� �et� L_— Address 340 1i ' Davis Fes} Rd Drillerortrainee License No. 1 706 tr City,State,Zip Bel€air, WA 98528 Contractor's 1fTRAgNEE. DAWSDI11 QOA Date ril � DrillePt:•signature No. Registration No. a 0_ Driller's Signature Ecology is an Equal Opportunity Employer. ECY 050-1-20(Rev 2/03) Thurston County Environmental Health 412 Lilly Rd NE 6 Olympia,WA 98506 36O'867-2631 THiJRSPDN COUNTY COLIFORM BACTERIA ANALYSIS 625 Zpll Time Sample County Collected III�� I `/ . �El AAAMM IA!1 CC�I Month Day Year •! J— , ` ✓ , Type of Water System(check only one box) vote Household ❑GroupA ❑Group B Other____________ Group A and Group B Systems—Provide from Wat Gl�besJodento ((�VFt � ID# . w System Name: Contact Person: ' k'-" Day Phone: 6, ) '2-a L — l c.1c7 I Phone: o. L E-mail: ' tea GCe Eve.Phone. a . Send results to:(Print fu nary a`a' s�anc de it ad`1es M SAMPLE INF0RMATN Sample,collected by(name): (-,--I c ,5 Specific location or address where sample colt red: Special in ions or comments: 2-3 % t . JV 450,E Type:of Sa pre(must check only one box of#1 through#4 listed below) putine 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.coil—GWR(NP) ❑Fecal.—surface,Owl,springs(numeration) Unsatisfactory routine lab number: Filtered'Yes___.No_ ❑Assessment Monitoring(AlP) Unsatisfactory routine collect date: ❑Other / / S 4)k1Sample;Collected for Information Only lw Investigative Construction I Repairs Other ' LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory'Total Coliform Present and Satisfactory O E.coli present ❑Ecoli absent No Coliform detected Replacement Sample Required. : ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density,Results:Total ColiforM /100ml, Ecoli 1100ml. Fecal Cplifotm 1100ml Enterococci /100 ml. Method.Cod SM 9223B ❑SM 9222D atee an Time Received: t]SM 92158 ❑Enterolert® t'ec (' VI Date and Time Analyzed: t ),. : Date Reported: I—2. — ' Sample Number(DOk numbe(plus rive digits) Lab Use Only: (, - n � $ O of DOH Forrnyt331-319(revised 11123) 7ZcL4h