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HomeMy WebLinkAboutWAT2026-00177 - WAT Application - 9/2/2026 WAT 2026 - 00177 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 s• 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:— k`. E)() �ij� !� Date: "� 7` � Mailing Address: (!/k `L �/J 5j t qgt/ L( Phone: y---5tl6=Q 7-L/Z.. Parcel Number: 32211 7J©D/GA( Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 9' Building permit BLD2026-00806 connections) O Division of land: 1 Individual water source (one connection), #of Parcels? SPL Well O Boundary line adjustment O 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 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. 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 1 15 ft. 05/03/2023 0" Well capacity Test (attached to application) 15 gpm >400 gpd. 05/03/20 3 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). 06/29/2026 Water Resource Inventory Area (WRIA) Development wit m RIA htt :// is.co.mason.wa.us/ tannin _ 16_22_ Water use or limitation recorde ............................... N/A Yes ned ............................................................... 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). Eli APPROVED Reviewer's Signatures: Environ. Health: Date 09/02/2026 CSD Director: Date 242 Spectra Labs-Kitsap,LLC (Poulsbo) SPECTRA.Laboratories-Kitsap 26276 Twelve Trees Ln NW,Ste.C ...Where experience millers Poulsbo,WA 98370 Phone: (360)779-5141 www.spectra-lab.com www.spectra-lab.com Spectra Labs-Kitsap,LLC (Poulsbo)received samples for Chris Dryer on Monday,June 29,2026 at 3:44 pm,Unless otherwise noted,all samples-were received in good condition and were tested in accordance with the laboratory's quality control procedures.A summary of the samples received are outlined below, Sample No. Description Location Sampled 263438-01 06129/2026115:04 263438-02 Spigot 06129/2026.15.05 This report package contains laboratory sample results and any attachments listed below.If you haute any questions please call(360)7799.5141 or email us at www.speetra-iab.com. Attachments 01) 02) This report is issued solely for the use of the person or company to whoin it is addressed.Any use,copying or disclosure other Than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories, 07106/2026 Page 1oft 26276 Twelve Trees 1..n NW,Ste.C Jpia Poulsbo,WA 98370 .P T A Laboratories Kitsap (360)779-5141 ,..Where experience matters IOC TEST PANEL Complete or Selected Inorganics System ID No: System Group Type: Private Sample Number: 010-43802 System Name: Sample Location: spigot County: Mason Sampler: Chris Dryer Source Nurnber(s): Sampler Phone No: Sample Purpose: Pelnnitting Date Collected: 06/29/2026 15:05 Sample Composition; single Source Date Received: 06/291202615;94 Sample Type: Untreated:DW Date Reported: 716/2026 Send Report to: Bill to: Chris Dryer Chris Dryer 3402 Harbel Dr Nil 3402 Harbel Dr NE Bremerton,WA 98310 Bremerton,WA 98310 DOH 4 Anelyte _ Results •Qual. Units SDRL PQL Trigger MCL Exceed Method Analyst Analysis MCL Date 0020 NhIratN NO U mg!L 0.5 0.1476 b 10 •SM4500 NO3 F ZA3 06!20/2621:41 NOTES: "Confirmat€on Include the original lab number,sample number,and collection date of original samplein eilherlab or sampler comments sect€on. RI., (State Detection Reporting Limit)The minimum reportable detection of an acolyte as established by the department.. Trigger Level: DOtt drinking water response level.Systems with compounds detected at concentrations in excess of this level may be required to take additional samples or monitor snore frequently.Please contactyour D0K drinking water regional office for further information. PALL: (Maximum Contaminant Level)if the contaminant amount exceeds the MCL,please contact your regional UGH office to determine follow-up actions. NA: (Not Analyzed)In the results column,indicates this compound was not included in the current analysis. ND: (Nat Detected)In the results column,indicates this compound was analyzed and not detected et a level greater than or equal to the SDRL. The compound was not detected In the sample at or above the concentration indicated(usually the lab method reporting limit). mglL: milligrams per liter or parts per miidon. NTU: nephotometrie turbidity units(a measure of water clarity). pmhosfcm: Micro ohms per centimeter(a measure of the ability of the water to conduct electricity).One micro ohm percentmetoris equivalent to one micro demon per centimeter(uWlcm). No existing trigger or MCL value. 1: Secondary MCL(Established for aesthetic purposes,not health based), 263438-02 Page 1.of 2 26276 Twelve Trees Lit NW,Ste.C Poulsbo,WA 98370 SPECTRA Laboratories - Kitsap (360)779-S 141 .Where experience matters Final Page of Report Isq QuaItlitars Qoi meets: U This analyze is not detected above the method reporting limit(MRL)or practical quantization limit(PQL),or if noted,not detected above the limit of detection(LOD)or method detection limit(MDL or DL). This report is issued solely for the use of the person or company to whom it is addressed.Any rise,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy ibis report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express Written approval by Spectre Lnbomtories. Approved By Jason Patrick Laboratory Manager 263438-02 Page 2 of 2 26276 Twelve Trees Lo NW Ste.C SPECTRA Laboratories Kitsap Poulsbo,WA 98370 ..Where aLpUTfCt m- tern (360)779-5141' COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Tlme Sample J County Ø(p ' .201 Collected DAM p101*! Type of Water System(check only one box) 0 Group A O Group B r Group A and Group B Systems—Provide from Water Facilities Inventory(WFl): lD# System Name, Contact Person.C t4 nI S d yt Yrc 1'` Day Phone: i Cell Phorre: Email: TNEN.1Sr -k P1 )IO&,K [+►-.41! , CO , Send resula fa:(P e:hi name,address sad vD cade) f1.1s Ot ?E- 34m1 t44kl3ItL , n, Nh an-o rlkkk 1'< tAIA -19310 SAMPLE INFORMATION Sample collected by(name): AIX15 0W'eL.I', Specific location where sample cotecfad: Special instructions or comments: Type of Sample(check only one box) 1.0 Routine Distribution Sample(AIP) 2.0 Repeat Sample(WP) Cho noted:Yes 0 No Ihwn d,s':,a.mon n alar unsaL rwrtne) Unsatisfactory roue ne lab number. Chlorine Residual:Total--Free, 3.Ground Water Rule Source Sample Unsatisfactory routine collect data: $ l� Chlorinated:Yes Nc o Triggered(AIP) Chlorine Residual:Total�Free_ O Assessment(N 4-Surface or GWI Raw Source Water Sample(Enumeration) I S I l ❑ E.tort ❑Fecal FO .n n Ys 7ao� ©Sample Cotected for MfurmaOan Only. L Pnr1{e Reucm )<Garr an/Repaha LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY ©Unsatisfactory Total Colfcm.Present and Satisfactory O E.cok oresenl ❑E.ncfi absent Bacterial Density Results:Total Ccliform mpN10lt1nt.E.eo# rrµxrf10oml. Fecal Coliform cfu"il3Drnl. 1{PC tdttllrtd Replacement Sample Required: 0 TNTC ❑Sample too old © Sample Vo1,irre ❑Darnaged Container j lwTm r Rem 'e€- \ \) \ Lab Reference Number RecelptTempC'- xnn Method Code:�_�!(OT-COUNJSM922an Daw10: Date out n.,epnn sfeaw sdelrratl rueyerivmam pa trm j einaiir aMressel Nrtrne.errj7Yipabsdew!e dtc6ai Mine r /2 /� �lYrawE eec+PVYis u�x�aa�a.eywh�.erwrao en,oreln Ia ( ej .oa.aeaee mwY the saq� r ei.yaa 3Ec rrs-sis7 ne mssarlEsre°m Pte'. DOH Lab-Sample# ' Tb—,-jb Mad alt ume Ears'."tw awns eerrpe(>}es Mn - ap e4 by�r Yeas aY.7M1a epaishNnelEe r{eodacefamp �------� mbLw+itrnl POQ.»n770, 0�IGts rmaaa.r. Doe Fam E3d73791eee6.>Qrwsn A!u t_.� _-. i- J 26276 Twelve Trces Ln NW Stc.C SPEC,"I'RA Laboratories Kitsap Poolabo.WA 98370 W/rcrs tare rsrurus (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample 1 County 12.t f .T�$fa Collected p lus py� Montt bay Year fry.3 : RPM 1 ' _ Type of Water System(check only one box) ❑Group A []Group 8 er Group A and Group 8 Systems—Provide from Water FaciGfies Inventory(WFI): lop System Name: Contact Person:C 14►L1 S D A i't:— Day Phone. Cell Phone: Email: TMk N4Sr .. .►'14A./nlit-e trIv+41L, tOX Send results to:(Prod hdaaree.address adry wda) ZAPL1S Oi'iYltl- 340.t I4A.rU3 Q 1, ion. A)Ii 13 r2 Gry f1 rZ T J, t A ' ft 3 P cL SAMPLE INFORMATION Sample collected by(name); C.,N IZ 15 _i). !Z tt Specific location where sample collected: Special instnrctions or comments: Type of Sample{check only one Dori 1.❑Routine Distribution Sample(NP) 2.❑ Repeal Sample(NP) Chlorinated:Yes ❑ No 63 lkom distaibraion system after unsal.routne) Unsatisfactory routine lab number. Chlorine Residual Total Free- 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: n i Cblcrinated:Yes No_ ❑Triggered(AJP) Chlorine Residual:Total Free_ ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) I` [] E.calf ❑Fecal nserea Yes- NN0 I r 5.©Sample Cotecled tar Information Only. I—. eReafdence )Car*rcaord Repai.s LAB USE ONLY DRINKING WATER RESULTS LAB 115E ONLY 0 Unsatiefactory Total CWRlorm Present and ©Satisfactory ❑E.cof present ❑Ecol absent Bacterial Density Result$:Total Colfarm mpn1100ml.E.cof mpnl100ml. Fecal Col form eful100ml. HPC ciulirrd. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Voiame ©damaged Canlainer ❑ I _ DatefRmnRecepv \GJU` \ i tab Reference Number Receipt Tamp C': Z,.y Method Code: SI I9223B I OT-COUNT)5M9222D Data kx hate fhd: 7risregxtieu ,. yIC tie usedre pexKn Ar —, mmparym wranits P.1.d.Nry�. »v0ol, cmu iII .a. rwdymA'n CC 0 tea/a rew7 4I rsd in .ea.7feefe tagt!fediu m'>a+bytl 3t=i Tf9.55Mt rd DOt1 Lab-Sample# Th.,.rr.b ICVA Ct to du fir, dadPesmAK'nite n \ \ rstaNeabre.eae ay.ltis reon Yasrri oeilw e.sioupt Y�©-� �1, v \ nlwl.«rP rt7+ucq.'rss rw+9m eoit<+er trr�AeQ++r�nrruia;. 505 FeaOM419[tlre 5 65rt7) SPECTRA Laboratories—Kitsap, LLC DRINKING WATER SAMPLE INFORMATION (WSI)FOR INORGANIC CHEMICAL ANALYSIS See Sampling Instructions on back of page Quote# 1.System ID No: 2.System Name: 3.Group(circle) Priv A 4.Sample Location: 5.Date/Time Collected: Lab Number Lab useonly 6.Sample Collected By: 7.Sampler Phone Number: 8.Sst:t e:(Circle one) H ai$ fl s Y i- 715 -(,(ci 'I G 1 Y, Untreated (jaw Treated Unknown 9.County:(circle one) 10. Sample Purpo 11.S Camposition l2. Source No(s) — Kits - C 7ieTsori — - Single Source Pierce Thurston ❑Routine Compliance 0 Blended Island King Grays Harbor SA Permit _ Y d Composite —'------� Other: U Other,Investigative ❑ Distribution ��—13.Send Report To:(Print Name,Address;Zip Code) 14.Phone No.: ?i S' - Ci G r c4rU f j3 k L tt;ti Li 1.4.Fox No.: 16.Email: T N Ii t',.4 S t^i..yp t-<1 NrJ l2P' çrr+.gtt 'cf. 17.Special instructions: Analysis OPrimary IOC Re uestetl Qinorganic Chemicals,IOC DKitsap 5(No,-N,Fe,Mn Ct',Cond) (Sb,Ae,Ba,Be,Cd,Cr,CNF, q (Group A&B systems) Hg,Pll$e,T1,NOrN,NO2-N, (Sb,Ae,Ba,Be,Cd,Cr,CN,F,Hg,Ni,Se,T1, CIPierce County IOC Na,Turb,Ph,Ca) Check a NO3-N,NOrN,CHc,Mn,Ag,SO4,?.n,Na, (Sb,At,Ha,Be,Cd,Cr,CTi,I H NiSeTI, group hard mnd,tnrb,cotor,Pb,Ca) NO, -N,Fe.Mn,Na,turb,Pb,Cu) ❑Other(circle or circle individual individual itrate only OJefferson County(NorN,Cl) test or write in new test tests below below, EPA I EPA REGULATED EPA REGULATED STATE UNREGULATED REGULATED (Seconds REGULATED Antimony(Sb) Nitrate-N(NO3-N) Chloride(C1-) Sodium(Na) Alkalinity Arsenic(As) 9 Nitrite-N(NOs-N) Iron(Fe) Hardness Calcium(Ca) Barium(Ba) Total Nitrdte/Nilrite Manganese(Mn) Conductivity Magnesium(Mg) Beryllium(Be) Nickel(Ni) Silver(Ag) Turbidity Potassium(K) Cadmium(Cd) Selenium(Se) 1 Sulfate(SOg2) Color pH Other: (list) Chlorine Residual (circle) Chromium(Cr) Thallium(TI) Zinc(Zn) Free and/or Total Cyanide{CI�l) STATE Total Organic Carbon Orthophosphate-P UNREGULATED TOC PO4-P. Fluoride(F-) j Lead(Pb) Total Dissolved Solids Sulfide(I-12S) Mercury(Hg) Copper(Cu) Bromate(BrO3-) Tannin Sample $ ature Date lY3rne: Rettoqui3rea By: plzyl ' 3:wi` Sanipie Received Signature j Date tne: \ Condition and Temperature on Receipt: 26276 Twelv ts' e Suite C A Poulsbo WA 98370A 360 779-5141 A Fax: '60 779-5150 A ua w.Si cr.tri lab coo S:IAdministratve\Forms and TempiateslTemp:ateslSamplc Manasemeni\Cti rent WS1 FormtUOC Faint Rev 6.2 05202 i.doc Revision date 052021 a- Is Is B -o o WA FN WELL REPORT DEPARTMENT OF Notice oflntentNo. WE52921 - ECOLOGY Unique Ecology Well ID Tag No. BPF01 1 o Type of Work: State of Washington e°o R Construction Site Well Name(if more titan one well): e ❑ Decommission Original installation NOI No. Water Right PemtitlCertiticate No. ' Proposed Use: f7 Domestic ❑Industrial ❑Municipal Property Owner Name Christopher Dryer o ❑Dewatering 0 Irrigation ❑Test Well ❑Other Well Street Address 961 NE Tahuya River Rd. Construction Type: Method: K New well ❑Alteration ❑Driven ❑Jetted ❑Cable"Iool City Tahuya County Mason ❑Deepening ❑Other ❑Dug n Air- ❑Mud-Rotary Tax Parcel No. 322127500100 s Dimensions: Diameter of b 6 in,,to 117 fl. ft boring Was a variance approved for this well? ❑Yes I]No a Depth of completed well 115 ft. If yes,what was the variance foal Construction Details- Wall cCasing Liner Diameter From To Thickness Steel PVC Welded Thread = l3 I ❑ 6 in. 0 1155 .025 in. [ I U J I ❑ Location(see instructions on page 2): ®W14TM or O EWM y ❑ I ❑ in. In- ❑ I ❑ ❑ I ❑ SE '/<'hofthe NW '/,;Section 12 Township 22N Range 3W DID in. in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.413269 Longitude(Example:-120.12345) -123.008019 = Perforations: 0 Yes ❑. No Type of perforator used o = Size ofperforatians in.by m_ Driller's Log/Construction or Decommission Procedure No.of perforations Formation:Describe by color,character,size of material and structure,and the kind and s Perforated from ft.to ft.below ground surface en nature of(he material in each layer penetrated,with at least one entry for each change of Screens: ❑Yes RI No ❑K-Packer n > Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To . Type Model No. Diameter Slot size in.from ft.to ff. Brown silty sand and gravel,cobbles, loose 0 6 Diameter Slot size in.from ft.to ft. Brown silty sand and gravel,tight 6 23 Borwn medium sand,silt 23 55 Sand/Filter pack:❑Yes L7 No Size of pack material in. Materials placed from ft.to ft Brown medium to coarse sand,multicolored 55 pea gravle,silt,wet 58 Surface Seat: ii Yes ❑No To shat depth? 18 ft_ Material used in seal Bentonite Chips Brown sill sand, ravel 58 94 Did any strata contain unusable water? ❑Yes E7 No Multicolored gravel,brown medium to coarse 94 Type of water? Depth of strata sand,water 115 Method of sealing strata off Multicolored gravel, brown fine to medium 115 sand,less,water 117 Pump: Manufacturer's Name Type: ILP. Pump intake depth: R. Designed flow rate: gpm \rater Levels: Land-surface elevation above mean sea level 180 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 71 ft.below top of well casing Date 5/30/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? N No ❑Yes by whom? Yield gpm with ft.drawdown after firs. _ Yield gpm with_ft-drawdown after hrs. Yield gpm with_ft.drawdown after hrs- Recovery data(time—zero when pump is,turned 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 15 gpm with stem set at 100 ft.Far 1 hrs. Date 5130/23 Artesian(low gpm Temperature of water 50 'F Was a chemical analysis made? ❑Yes W7 No Start Date 5130/23 Completed Date 5/30/23 WELL CONSTRUCTION CER'C1FICATION: I constntcted 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. D Driller❑Trainee❑P11—Ni acne Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADD1098KI Date 5/30123 ECY 050-1-20(Rev 09/18) Ifyou geed this document in an alternate formal,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for IV'ashtngton Relay Service. Persons with a speech disability can call 877-833-6341.