HomeMy WebLinkAboutWAT2026-00122 - WAT Application - 7/24/2026 WAT 2026-0-0122
MASON COUNTY
*14I1Shelton,WA 98584
Shelton:360 427-9 670,.Ex t.400
` ! Public Health & Human Services Belfairr360-275-4467,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: u t ] Date: �
Mailing Address: t J_ /S _ $J' Phone: 360 - �7 7o - t-z .3 '3
Parcel Number: L• z-13 L3 ,L OQC 7C7
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
0 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.
See WEL2024-00043
Part 2: Water Connection Information Two party well
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number: Z'P F/' 5 (write"none"for two-party)
❑ I am the manager of this Water system.The water system has been approved for I services.There
are presently I connection(s)in use.This will be the ?J&tp connection.
0 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 70 e -� - u-,"e l� Phone ' é `�76-) L 3
Signature of Water System Manager _ - -?4/ Date 7/ /2.C
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Forins\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 59 ft.
® Well capacity Test(attached to application) 15 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
❑ 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)
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(8).
Reviewer's Signatures:
Environ. Health: Date
7/24/2026
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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DEPARYMENTOF eofinletieNo. VVE56600
V 1�7ER Y1t 4L EPQRT Notic ECOLOGY tiriiquc Ecok,gy Well IDTogNO,PPF195
"rypt onvorw' State tit wwhington
.Sian Situ l'!°cll Name(if mssre than one well):
fJosotttt i ssiam t}rigZnal insedlation NO[N.a. Water Right Perut Cerulieate No,
Pcatvtssd Lis Ll Wi ie O indiapiai O kluaia:ipsi Property _ __-
° Nettie:Ted pahtn
Ct Uewaretio3 O ttrrgatitrn O Test Well O'Odxr Weil Street Address Bear rays Lit
mxato x: i ethod; City Steel Win County Mason
! ?dry wrstt [ Attrrat tva C3 ten a Jettcd 13 Cable'tatst
fl.> IT13Cilaet O Dug td 1io- F7 filud•ttotttty Tax Pnrcci l+v. 42132-31-0(}O6Ci
ltiangtutostsr&lssaonetrr;ortwsr lots 6 in,to 59 _ tt WaS a vsatiWtce dPproVC4 foe this\Wi? C1 Yes 0 Nu
t' pth ofttarapictcd+aoii 59 It,
ifyes. shat im that Vat a e for*,
{ a3tractoevt Rctuitrz }
ssng tier Dank r.`r From To Thickness Steel PVC Welded 11utad
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[ OD m min, Ci C3 1 C7
_r Latitude{G*rample:47,1 5t:47.26296 N
DID
Longitude(Example:=E2iti345) 123 218t?8
Pcrfarotiont ❑Yes i7 do T}tae of perforator ubetl ,<
Size of omt eau^iat,tai W _is Dr lIer LoWConstrpettaa or
T3esomtniss[ott Trrasetittrc
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Surface l3mt: fii 3 ra Cl too f a whet cpttiT 18 It
Brown fine&arid,One to Medium!U-colared 24
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Method o€nna1ing titota off
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ttR__Pwottirdakedepth.,••_5. Designed flow rates_Epm
3 rertepets.,tauuktnfaceetcvzlionabovc.mean nutlend
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well Tats:
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yield_Rpm with _ft,dcaw&wn after_his.
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tap to wash is wct)
frnac WalerLevel Time 4VnterLevel Time Water Level el
Dole of tontpuri test
e,tt,st ,, E m wit u
h,•_..�ft.drawdorvta niter,,A i
Baia
)rtoal j dtj,wlair seem ssr at AQ_,ft,fir 1 her. t me 7117
mpeentare of water. L.. F it to a ct rtnical nnatjsis nindci C9 es C+l ha Start Late 7117124 Completed Butte 7/17124
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[I Driller A Teas nce O PE-Print orY Johnson Drilling Company Areatria Orifg Inc.
Siaatuse
Added PO Box 1796
LicenseNir:3441T City State Zin SheilCn VYA 98884
IF£ alt '.S hr's Lied N S Contzatxor's
S nsaf`s 5i lure Registintion No ARCADD10g8K1 iaata,711712+}
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Printed from Mason County DMS
Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA.98584
Customer: 'Ted Dahrn Well Tag#: BPF195
Site.Address; Beargrass Lane,Shelton Depth: 59'
Date of Test; 712412024 Static: 21.5'
Pump Set: 40'
TIME GPM LEVEL RECOVERY
I Min 3 21.8 TIME LEVEL
2"Min 3 21.8 E 1 in 21..5
3 Mn 3 21.8
gi 3 21..8
5 Min 7.5 21.8
6lin 7:5 22.9
7 Min. 7.5 22.1
8 Min 7.5 22.1 �t
9Is}iin 7.5 22.1
10Min 15 22.1
15 Min 15 22.9
20 Min 15 22.9,
25 Min 15 22.9
30 Min 15: . 22.9'
35"Min ` 15 22.3
40 Min 15 22.9
45 Min 15 22.9
50 Min 15 22.9
55-Min 15 22.9
9 i•ir 15 22.9
1 Hr 10 Min 15 22.9
Prnted From Mason County OMS
Pñntd fr r€ Mason Cc.w ty OMS
- E
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506
360 867-2631 f,
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
C'7 12ta I 1�-6 ❑ +
Month Day Year
Type of Water System(check only one box) ❑ Private Household
❑Group A 0 Group B - I$Other 2-"
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:
Day Phone:("x 6 j ''70 . Z Cell Phone:( ) 1#t 1
E-mail: } (,� Eve.Phone:(
Send results to:(Print full name,address and zip code or email address)
�_ ..,,..., rr._............. ./. y.....
SAMPLE INFORMATION
Sample collected by(name): �•
Specific location or address where sample collected: Special instructions or comments:
F -! ;2I 000 7 f.
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine 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.colt—GWR(NP) �!
❑Fecal—Surta e,Owl,springs inumeraeon) Unsatisfactory routine lab number:
Filtered:Yes_No_
Assessment Monitoring(NP) Unsatisfactory routine collect date:
❑Other 1 /
S
4.❑Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑:Unsatisfactory Total Coliform Present and Satisfactory
0 E.coli present ❑E.coli absent oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Coliform /100ml. E.coli /100ml.
Fecal Coliform 1100mI Enterococci /100 ml.
Method Coder SM 9223B ❑SM 9222D Date and Time Received:
❑SM 92158 ❑Enterolert0 t%
Date and Time Analyzed: 0 1.A Date Reported: - -. 'j
Sample Number(DOH number plus rive digits) Lab Use Only:
.
DOH Form(+331319(mooed 11123)
c