HomeMy WebLinkAboutWAT2026-00172 - WAT Application - 8/20/2026 (2) WAT 2026-00172
MASON Shelton. A Stre 4
Shelton,WA 9884
Public Health & Human Services Shelton: 360-275-4467.Ext.400
Belfair: X60-275--I-I67.Et-I00
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: Caitlin Gartrell Date:
Mailing Address: 3616 W Arsenal Way Bremerton WA 98312 Phone: 360-689-7848
Parcel Number: 223107900760
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit
connections) 0 Division of land:
0 Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0
❑ 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)
❑ 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 1 of?
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
lyI Water well report(attached to application). Depth 1 52 ft.
II Well capacity Test (attached to application) 20 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.
El 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)
XJ 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.
H Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
kI , Reviewer's Signatures:
8/20/26
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT tl fsAttTMfblT Or Noticedal'lutentNo. WE61494
flnkille l ology Well ft lug No, 17 4
}1t 4 uekt state of Wahton
Construction Site Well Ntttnc(iftrtoro than one wall);
O D aneewn Original taItaIon Not No. Water R igl It Perinit/Certificaio No,,
Pspared War tlomitlio f Industrial unho nd Property Owner Name jAITLI CnAl 1 t t l
Li Dewettarbig U Initiation U Tost well C;f Crther �=
n'slruettan Tytnct Ivlelltadlt Well Street Address 17th tlC Yltl Y f,FZ, „ �
Cpl New well UAlienation U Ilrfvan U laved CJ cable Toot City (CAC 2 county MA t N (F
Deepaninfg t t Other i Dog U Airs 11 M€d Rotary "fix Parcel No. 3'f f179t}Q760
Dfmrtaat'os:DEarae€er orinS frt m 1 ' 16
Depth of completed well 16 it, W's n variance approved lire Ibis welt? ''es No
s lfyce,what was file variance foal
t'oostrucllionD tails: Walt
Cann i Litter tlutntcter From To Tbirkncss Steel PVC Welded Thread
l 0 in. a1,S' t41° ... L I . I U t 0 Location(see iraotructions on page 2): l l WWM or f WM
in, n„ in. UU 0 1 0 N dl nrtlto Nlrl f;Section 19 Township N Range
l fit- in t 1
o j CI ln. u o Cl t CI Latitude(Pxntntple;47,12345)77
Perforations: D Yes No 'type ofperromtor used., Longitude ritudd (Example:�1 f1,t 234S1 -1 .92
No,ofperfotalions Sue of petfd3nttintt=a In.bY, „��,.in, Di llter'tt t,rltottatritctlon 4tr'flecortt€tnl5sftlRt Procedure t-
Petitioned(rein-ft.to #t below ground aurfece Formation,ticacril by color,character,917,0 ofrranorktl and strocrw€e,and the kind and
nature of Ito material in each layer penetrated,with at least one entry for each change of
Screens. f Yes t No f d K€packer Depth 146 u. tofiar'uatian Uas additional ahceta ifnecessary,
f laaaibeturer'a Name JOHNSON
Ty TEL SCC}PtAIt3 Model No. Material FromD
Dlamctcr „;,; Sint si ,Q Q in,ftxam I ti<to 1 fl. FROWN l fARI I AN '
Diameter in, Slat alee in front tt.to,,,,,,,,,,, ft. SR0NN AN IG f AV L WILl 145' - 1 '
ROWN HARPAN 152'
Saari/Fltterpaeld,0 Yea li No Size at pack materIttt, „ In.
Materials placed from K ,,,,,ft.to-
ft
Surface Scat. Yes U No To what depth? 1S L
Material rated in marl RENTONITR CHIPS
Did any strait contain ontriabio water? ]Yea No
'rypaorwstr7 Deptborstrata,
Method ofsealiatgg stratta off
Poulin Mannlbewwr"s Naute Cyfte:
ILP. �, ,, Pump hfrako deplt: fl, Designed flow rata; Spm
Water l.avelat 1,anui aoefaea elevation above rneett ace level 4
Stick-up ortop of well caning 1,5 ft.above Around cortaca
Static water level..J!L ti.below top orwetl unstop !late 1 t977t
Artesianpore-area the,per aleareinch Date
Artealen water Is eprnml ed by . (cap,valve,etc.)
Writ Teti it 1I
Was a pumping teat performed? No f:i Yea r.. a by whootar
Yield gam with„„„„„,,,,fl,doawdown after lira,
Yield „,,,,,,,put with, ,,, ft,draw dawn after bra.
Yield "m with,,m,,,fl,drawdownafter , lire,
Recovery data(hroe-moo when pump is tended off—water level nreastared from well
top to water level)
'rime Water Level Time Water level Time Water Level
Date ofpttmpingglest „z
lfallar test fl Spin with 7 ft..dmwdown after.,,,,,, lire.] -.-.- , ,.., ,,.-, ,,,,.,,- ' ' "
Air teat m with stem set at., ,,ft roc 111771"25�»t4€t �. ,.�idea, i7tata,�.,..„
Arfhitt flow pgaru
Temperature of water a P Was a ehetngrr₹l analyala made? Cl Yea liii No Stas1 Mato 1111 dl f)9S tom.let d Data 11 T f ttl S
WELL Lla tJtt S VIL J `Tlfll5l CERTIPlCATlON. I construct .l and/or wept responsIbility for construction of this well,and its coniplianee with till Washington wall
construction standards.Materials used and die Information reported above are true to nay best knowlecle and betiefi
Driller 'f pl rtnt2ltarrte ptAYM N lm CI rlllin daarn azt pAl l ltd f l» F[l l ll ,[tE
Si "'tore Address 09 NW WESLEY WAY Illj
l�lecrtaoNo, 1rf9 wit tutu l FflJlt,WA 91 ?9
1p TRAM IRl1x S tumor's lceaake 1°er, onttcttr's
ottxor's f i rttnluro .. fta atau"Igo. L FAl W 9 9 l l gala 111 131 f1 S
E Y 0511.140 0(R.ev 08119)1 you need this doctrine'in art alrtr°»ala fbrntoe,plaftse coil 11w Water Resources Program!ax 360-407-4871
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PRIVATE WATER SUPPLY DESIGN
System Designed for (mwxtrert located at(property
address or legal description) 7 �recsr,
This design If for(chock one) n to Pamit Residence. OR Twa Party Prive Well
urnps Pump rate t
a,thetogv/red daily rgs(ng jamtly€eslde
two pnrFyprlYatea an mot he complete
iced Pump hand,
Wellhead
(S.t (.rbrawdown 1 PumpSetectedh Attach pump curve/table
mss. 7 a.a a �.r.._. .._-..,