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HomeMy WebLinkAboutWAT2026-00135 - WAT Application - 7/16/2026 WAT 2026-00135 MASON COUNTY 415,.6"Street Sitdmn,Wn 9x5x4 Shelton:360.427-9670,Ext.400 Public Health & Human Services Beffair:360-275.4467.ext.400 Application for Determination of Water Adequacy Instructions 1. .Complete Part 1, No determination can be made until Part I 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. M approved building site plan must accompany this application. Part 1: Applicant! Parcel Identification Name of Applicant: =e x)*—r - u41e: , o — Mailing Address: I NF,�v _u1 (7�—Phone: t (oo OS cO Parcel Number ji2) !) _2,2L(xz,( U Type of Water System Reason for Application itt Public/Community p Water System(2 or more tp\Building permit t" connections) O Division of land: ❑ Individual water source(one connection), it of Parcels? SPI. ❑ Well ❑ Boundary line adjustment Cl Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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 Publlc/Communfty 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: `2._W7e,k) —r _ rrrWater Facility Inventory(WFI)Num ter: {k (write"none"for two-party) the manager of this water system.The water system has been Jproved for 2_.services.There r 'ire presently I connection(s)in use.This will be the 7 . connection, ❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system(Le.: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)conneotlon(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 �ZC (z0'l Signature of Water System Manager Date This form may be scanned and available for public view at i w,masoncounty a au�o�v�-(� J:EH Fomrs\Drinking Watcr Ravisml05/08/2024 Page I oft Group 8 Water Systems �Satlafactory bacteriological test within last year(attach to application). Individual Water Wail f5d Water well report(attached to application). Depth V >400 ppU. Well ell il oft n performs rd mso application)apcn) Pn' The well driller often performs well capacity tests et the lImethe 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 teat,which provides stabilization of draw•down and recovery date, 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 ons per❑ pro ides water ate irate of 2ieve tgallons per minute based on the following obas water aoure can provide at east 800 lervetl day;and/or ons. Author of Statement Date Relationship to Applicant Part 3: Mason County Community Services Evaluation (staff use only) FlUnsatiefactory ctory Determination: rmination does not address adequacy of the distribution system,guarantee an adequate supply of wa approval ndicates requirements of with Sanitary Code,applicable n h tle a, apter9 68.040-Determn Recommended anon of y for Building Permits are satisfied, Additional Growth Management requirements may apply. Chapter CW. sfactory Determination: ts water supply does not appear adequate to meet the needs of Its Intended use for the following ).� - Reviewer's Signatures: ys Date 7/16/2026 Environ. Health: This form may be scanned and available for public view at www,masonooantyWB.noy I'ogo 2 or2 DEPARTMENT OF Notice of Intent No. WE61892 WATER WELL REPORT ECOLOGY Unique Ecology Well ID Tag No BOC410 Type of Work: state of Washington Sone '.] C a Site Well (if m m w'elpt ❑ Deeo,mitssion b Origl 1- WI - nNOIN fiOU18 Water Right Pe it/C rff 1 No. _ I Municipal Property 0 Nam Ka &Pagpy Van Buskirk Prop G Do ❑Indusrt ❑Mumn Iv t N l D mla D In0 ❑ feet W II D 0 Mr. Well Street Address 11)60 NE Sand kll Rd Construction Type Method: City Bella, _ County Mason ❑New well aE Alteration SgMiven 0 rend Lad Cable Tool E Dccpening 0 other 0 Dog ❑Air- ❑Mw Rotary Tax Parcel No. 123203300010 Dimemloaa: Diameto ofbodng6 m.,to 113 R. Wasavariance approved for this wells C Yes e�No '�trro /LJ _________________Depth orcotupteted 11113 R. If yes,what W0.c the vacuae for? - " Croetruelim Oetai6: Wall Casing Liner Dlt iaete: Frans To 11 k::ae Steel PVC Welded TNaad WWM or❑EWM n ❑ e n +8" 113 114 in. ❑a 1 0 0 I C Lacaoon(see mstmdlons on page 2)'. 0 r. ❑ I ❑ ❑ ❑ SW V.-'/.ofthe SW A;Section 20 TowmM1ip 23rd Range 1W ❑ I ❑ —n C I ❑ ❑ I ❑ Latitude lExemple'47.12345) 4].46468 _ 171C i - — C I ❑ ❑ ❑ 2249 -_ ' m. Longitude(Example:-120.12345) -1 811 Horaho ; m 0 Yes Oa No Type ofperrommrwd Driller's Log/Coastrurtloa or Decommission Procedure !pert ( Size ofperto _in.by ii Formation Describe by 1 character,sizeormatedel and smetme and the kind and d f R.to P.below you d urh<e f l riot n I layer pe nmed,with at least envy f each change of e 0 Y Yes C No ❑K P k b Depth_ .ft. - f 1 aeat nal h f eexvry. uu s Na:ere M t l From I'o e Floal loo' extension and surface seal to complete formermade_ in Slot sae in,from ft to_R. Diameter in. Slot ixe_ in from f ta___P. pit completion mourot er pock:❑Yee eu No Size of pad[materiel_ 6"casing welded on +B" 4' Materials placed from f.to _ft 10"+bentonite Surface seal 0 2 Surface Seal: G Yes ONo To what depth? 275 ft. t0"+cement surface seal 2 5 M1lutc[ial used in seal bentonitel cement Did any strata contain unusable water? ❑Ycs '3 No Type nfwalefl _ Patch-fao-ma_ ____ _ ______ H Method of cling antsafi Pump: Manuhdu[ers Ntme05 Type'. sub HP. 3 Pomp intake deptk 1100 R. Designed flow \Varer Levels: Land-surface elevation above man sea level_flc Slick-tip of lop nfwell caso11-66 R.above ground surface Static water level 92 R.below tap ofwell cooing Pate 11R1Q5 Anaun pressure Ibz,per equemin=h Date - Anesian water is controlled by (cap,vabq em.) Well Tests: Was a.me...g teat performed? No LI Yes b by wbome Yield gpm with 0.dmwdoavn after__tus. witM1_ P.Javtlown anv_hn. — 'op o gem with_ -0-mawdoxnn ate, hrs. Rec Recovery do. rime-um when Pu:aphe turned oil—water level in a eel fro in well Tim, _____ H mole a) Water Level Ti me Wemrls'd Time Water Level Date or pumping teat_ Bailer with G.drawdown after 1uz Air test_gpm with stem set m_ ft.for hre. r Date_ Aneeia"tow_"'in J Tcmperamre ofwater a F Was a chemical analysis made? ❑Yes D No Start Date 1117126 7/26 - - Completed Date 111788 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of This will,and its compliance with all Washington well consWdion standards.Materials used and the information reported above are has to my best know1edgc and belief 0 Driller❑Trainee❑PE—Print Name Mike Davis Drilling Company Davis Drilling Signature Address 340 NE Davis Farm Rd License No- 0797 Cry Stat Zip Belfalr We 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsors Signature RegistrationNo.DaWsD11100A Date1/21/2026 ECY 050-1-20(Rev 08/19)Ifyouflee? hrs document in an ufternate for t,plea alld[e Warer Resources Program at 360407-6872. /+coma with Macho(¢,,can dn11711 jor Waslungbn Refky waifs P rsann irh a speech disabi/ft can call877-833-634!. `tai®VWI?L94 Inc. 3401 UL Vavin?arm 14 'Se(fair,'Wa 98528 (360)801-6107 MLevel ��2.0 en & Peggy Van3 AG: BQC410 11121/2025 3HP35GPM Well109 52.0' Draw Down Recovery P100.4' r Leval GPM 0 100.5' 0 tmin 92.2' ' 33 2 92.0 ' i 33 3 ' s34 30min . ' 33 5 1 hr 100.5 33 10 2 hr 100.5 33 20 Capacity Notes: - Vancuar0 Lahoruturc 2635 Ptlrknwut Lane SW. Suite A a ON atpla WA 9350'_ "`AAA 60-961-7010 COLIFORM BACTERIA ANALYSIS FORM Ome Sample conecte FIme Sam- Cwnry ell¢ I d Type dWater System lcF ec only o eooq fl Group?. ❑bap© DOther Group A and G'oup B Systems-Pi WOe`am Y`gml Facilities Ifventor,(W I): D sysiem Name i C petact Person'Arcadia Uniting Inc-' Da Pfinel 960-i 46339 CellPoeI alEve.Phone Send 1 :n I - —t Im xaAND; aa vvl SAMPLE INFORMATION. amnle coacted h,h. Lecific iocaton wlerpin ale collected: Speciol irislructio,isn comments —I Type of Sample(select nly one ripe of senate from ryras l lbrcugh 5 E_Wmv) 1 fl Routine 0'stributioil Sample API L 2 ❑ RepaatS pl (AIP) Ch!orirated Yes No a L o. Ur.sstactofl rnJl 6 oJmher Chlie Residual:Total Free 3 Ground Water Rule Source Somplx LnzaBtaclary routine calecl date: CR]rinated Yes No _ ❑Tryger&d(AP I t'nloa;e Residual Total -Free ❑Assesment ;n/P) 4 Surface or GWI Raw Source Water Saclple IEnmverurnl 5.Q Snm'ple cosccled M I rlorrcaoon Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY I]Unsatlslagpry TOIL ColVdmr Present and Sallslaztory ❑Emil prosent ❑F cn4"'di! �. Bacterial Density Results Tolei CCAlann_ _ :PJCmL E.mhh_ ;IOOmI. Om^Sample Volume ❑Oa aged Conla eaa ❑r - IJ ❑ml Ba:Rpac SampleI Required: ❑TNIG IT Sample oldlw J . • •1 12 Dale Roiled w CW. a OOH LZPsam 285- lzt L°( _r !r