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HomeMy WebLinkAboutWAT2026-00118 - WAT Application - 7/8/2026 WAT2o 2 - OO( 1 € MASON415 N.6'h Street CO U N TV Shelton,WA 98584 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 required attachments for review. 4. An approved building site plan must accompany this application. Part 1: Applicant! Parcel Identification Name on Applicant., ))fi.r t t" Date: Lo 5 -) Mailing Address:Z — � Q = �f tY -i�z�. Phone: t. Lail), L4 (Lp, ! L tF Parcel Number: 1 C3--lei - (3"1 1 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit `CD connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL ,,` Well ❑ 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. Part 2: Water Connection Information VJE .. 2b2 & ooO 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. ❑ 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]of2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well IA Water well report(attached to application). Depth 191 ft. L Well capacity Test(attached to application) 16 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. IN 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) 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 6.68.040-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(s). Reviewer's Signatures: 7/8/2026 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT DEPARTMENT of NoticeoflntentNo. WE62185 ECOLOGY Unique Ecology Well ID Tag No. BNM830 Type of Work: Sate of Washington Ll Construction Site Well Name(if more than one well): D Decommission r= Original installation NOt No. Water Right Permit/Certificate No. Proposed Use: I)Domestic 17 industrial 0 Municipal Property Owner Name LEGACY HOME CENTER 0 Dewatering ❑irrigation 0 Test Well 0 tidier Well Street Address 121 NE LAKEWAY N Construction Type Method; G2 New well D Alteration ©Driven r l Jetted 0 Cable Tool City BELFAIR County MASON 11 Deepening 0 Other 0 Dug ll Air- O Mud-Rotary Tax Parcel No. 223107<990711 Dimensions: Diameter of boring__6 in.,to 191 fL Was a variance approved for this well? 0 Yes IEI No Depth of completed well 191 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread I D 6 in. +1— 0— .25 in. l l [ 0 9 1 O Location(see instructions on page 2): IN WWM or O EWM 0 { 0 in. ____ in. 0 ( 0 D ! D NE Y4-V4 of the NW 'l;Secton 10 Township 23N Range_k. D {' D in. _ __ ____ in. D { D 0 1 Latitude(Example:47.12345) 47.50751 D { D in. — in. 13 j D D i G Longitude(Example:-120.12345) -122.91894 Perforations: O Yes i1 No Type of perforator used o. Nu.ofperForations Sizeofperforatioav in.lry in. Driller'sLog/ConstructionorDecommissionProcedure No.of per fr t i ft.to ft below o f e and pserforations Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: B]Yes D No fl K Packer Z?epth !t, information, Use additional sheets if necessary,. Manufacturer's Name Material From To Type STANLESS Model No. Diameter 6 in, Slot size 10 in,from 186 ft to 191 ft CLAY&GRAVEL BROWN 0 175 Diameter in. Siotcize in.from fl to fl. GRAVEL H2O BNROWN 175 191 o _ Sand/Filter paeir 0 Yes 9 No Size of pack material in. oMaterials placed from ft.to,,,,.. ,,,ft. t7 E Surface Seal: Q Yes 0 No To what depth?20 it; o Material used in seal BENTONITE Did any strata contazn unusable water? :C Yes No L Type of water? Depth of strata o Method of sealing strata off n Pump: Manufacturer's Name flfl1JLDS Type: SUB tI1'.JJJ Pump intake depth:11 8. Designed flow rate: 10 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing 1 ft,above ground surface r Static water level '1!r ft.below top of well casing Date 4-17-26 ` Artesian pressure lbs..per square inch Date Artesian water is controlled by (cap,"valve,etc.) L Well Tests:. Was a pumping test performed? 0 No IN Yes a by whom? Yield t6 gpm with j it drawdown after 4 tus. 7 Yield gpm with_ft.drawdovn after hrs. Yield gpm with—it drawdown after lets. 0 Recovery data(time—zero when pump is turned off--water level measured from well, top to water level) Time Water Level Time WaterLevel Time Water Level 5 135 _ RR U o Dare of pumping test C` Baiter test gpm with_It drawdown after_leis. E Air test; gpm with stem set at ft for_lees. Date Artesianfow- gain Temperature of water.. _'F Was a chemical analysis made? D Yes Cl No Start Date 3-24-26 Completed Date 3-31-26' WELL CONSTRUCTION CERTIFICATION:I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well G construction standards.Materials used and the information reported above are true to my best knowledge and belief. Driller 0 Trainee PE—Print.Name CLAY PITT'S Drilling Company COOLWATER DRTLLING,INC. Signature Address 10921 NW HOLLY RD License No. 2 16 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's onsnr's Si store' Registration No;COOLWDI941 QM Date 4-22-26 ECY'050-1-20(Rev 11/18) if you need this document in an alternate format;please call the Water Resources Program as 360.407-687?. Persons with hearing loss can call 7Il for Washington,Relay Service. Persons with a speech disability can call 26276"twelve: Trees La N tilt Ste.C aØrt Ec�x> Kt2P Poulsbo,WA 98370 _. .IVP�,ro ex erfencs mutters o(36i)?79-5141 c0L oR PAcT9R LY$S FQRM Date Sample Collected Time Sample County Collected MorM Day Year Type of Water System(check only one box) I:],group A, ❑Group B Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFl}: ID# SystemName: Contact Person: Cry' ti'z� Day Phone: 3 to— � Cell Phone: Etrtaa:rc���dua �grtl�c�aaGtr .Phone: st Sand results to:(Pent roil name.address.sad zrp code or email atovofor otetlrordc copy of resuSs) SAMPLE t4F{3RNiAT10N Sample collected by{Warne} ø ' iL r Specific ation where sample collected: Special instructbris or comments: Type of Sample(check only one box) _ .._ 1.❑Routine Distribution Sample(NP) 2.❑Repeat Sample(AlP) Chlorinated:Yes ❑ No❑ (from di$trbuiicnsystem after_mat.routine) Unsatisfactory routine lab number. Chlorine Residual:TotaLFree� 3.Ground Water Rule Source Sample —— — Unsatisfactory routine collect date: Chlorinated:Yes No ❑Triggered(AIP) Chlorine Residual:Total_,._._Free— ❑Assessment(AIP) 4.Surfaco or GlfdtRaw Source Water Sample(Enumeration) l i ❑ E call O Fecal nomad Yes No 5. Sample GoIIecEml f ►nforaaatiasr t)nty R C]Cotcattutx3atJ Rey�ska I AB US#=QNi THRI FQ YG YUA?R RESUi:TS` Las uSE o r�Y C!Unsatisfactery Total Col formm Present and Satisfactory ❑$.cell present ❑Ecati absent Bacterial Density Results:TotalColifomt mpnl140ml.Ecolf mpN100mL FecalColiform cF I100ml. HPG ;hglrnl. Replacement Sample Required: ❑TNTC 0 Sample too old o Sample Volume ❑Damaged Container 0 Oaf ucaTved tab Reference Number Receipt Tamp C'; ^} + MethadCode v"Stif9223 !QT_Col3tliJSt 222a Thu rayst�r., rmktr'for 4w use d tlm ttngt cayzry h Dar rrt: Date out, wnaetaacbesstJoy ao, rthro $f/IfoA d. . 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