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Home My WebLink AboutWAT2026-00115 - WAT Application - 6/26/2026 WAT 2026-00115 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 this application. Part 1: Applicant/ Parcel Identification Name on Applicant: V7 1" - \'r!?tk 7 C Date: 1. r ZG2--c, Mailing Address: 2bl N. Phone: c •-J`tc Parcel Number: b19oS 4 � - 0Ob2-C it lot 4 was tl�yti Va Reason for Application Type of Water System ❑ Public/Community Water System (2 or more Q,�i Building permit connections) b Division of land: t Individual water source (one connection), #of Parcels? SPL Well O Boundary line adjustment O Spring/surface water O 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 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. 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 Water well report (attached to application). Depth ft. >400 K Well capacity Test(attached to application) k c- gpm 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 (attach to application). r � Water Resource Inventory Area (WRIA) Development within which WRIA p1//qis.co.mason.wa.us/plannJflq 14 15 16 22_ Water use or limitation recorded................................... N/A Yes Well Drilled ....................................... ....................... Date 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) X 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: q�yvu�5 6/26/26 Environ. Health: Date CSD Director: Date 2°' WATER WELL REPORT DEPARTMENT OF Notice of Intent No.WE62748 Type of Work: '° te of Washington Unique Ecology Well ID Tag No.BRM486 Sta ® Construction Site Well Name(if more than one well): ❑ Decommission ey Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ®Domestic ❑Industrial ❑Municipal 0 Dewatering ❑Irrigation ❑Test Well ❑Other Property Owner Name DAHL PROPERTIES Well Street Address 0 W FORD LOOP RD LOT4 Construction Type: Method: . ®New well 0 Alteration ❑Driven ❑Jetted ❑Cable Tool City ELMA _ County MASON ❑Deepening ❑Other ❑Dug ®Air- 0 Mud-Rotary Tax Parcel No.619054400020 Dimensions: Diameter of boring 6 in.,to 57 ft. Depth of completed well 57 ft. Was a variance approved for this well? Yes ®No Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread ® 1 0 6 in. 1.5 57 .25 in. ® ❑ 0 I ❑ Location(see instructions on page 2): ®WWM or❑EWM ❑ 1 O in. in. ❑ I ❑ 0 ❑ ❑ ( ❑ in. in, ❑ I ❑ ❑ 1 ❑ SE'/u-¼of the SE /.;Section 5 Township 19N Range 6W ❑ 1 ❑ in, _ in. ❑ I ❑ 0 1 ❑ Latitude(Example:47.12345)47.15662 Perforations: ❑Yes ®No Type of perforator used Longitude(Example:-120.12345)-123.45208 No.of perforations_ Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Perforated from ft to ft below ground surface 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: ❑Yes 0 No 0 K-Packer 0 Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. BROWN SOIL,LARGE GRAVEL 0 8 Diameter_ Slot size infrom. _ft.to_ft, Diameter Slot size in from ft.to ft. LT BRN CLAY,COARSE SAND&GRAVEL 8 57 Sand/Filter pack:❑Yes 0 No Size of pack material in. Materials placed from ft.to ft. Surface Seal: 0 Yes ❑No To what depth?18+ft. Material used in seal BENTONITE Did any strata contain unusable water? ❑Yes ®No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: H.P. Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 66 ft. Stick-up of top of well casing 1_5 ft.above ground surface Static water level 28 ft.below top of well casing Date 4-30-26 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc) Well Tests: Was a pumping test performed? 0 No El Yes E4> by whom? Yield _gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time=zero when pump is tamed off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test—.._gpm with_ft.drawdown after_hrs. Air test 60 gpm with stem set at__,_ft.for 1 hrs. Date 4-30-26 Artesian flow_gpm Temperature of water °F Was a chemical analysis made? ❑Yes R No Stan Date 4-30-26 Completed Date 4-30-26 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 information reported above are true to my best knowledge and belief. ® Driller❑Trainee❑ E—Pint Name ERIC BRASHER Drilling Company KINGS WATER WELLS Signature Address 409-23 REINKE ROAD License No.3430 City,State,Zip CENTRALIA,WA 98531 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No KINGSWW937QM Date 3' S' ECY 050-1-20(Rev 09/18) Ifyou need this document in an alternate format,please coil the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. 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