HomeMy WebLinkAboutWAT2026-00179 - WAT Application - 8/10/2026 FAT 2026-0O.179
________P
415 N.6tb Street
MASON COUNTY Shelton-WA 98584
j COMMUNITY SERVICES Shenon:360-427-96/0-cxi 400
13e1(eir.3GV-275-4467.I'xt.4110
Building rknnhw rmnonmr nai Health.Community neam I 'ma:360-482-5^_69.I 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 115 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 Gary Bushnell Date:
Mailing Address: 781 NE Tahuya River Dr Phone 360-275-3248
Parcel Number: 222051200090
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more fffi Building permit
connections) O Division of land:
N Individual water source (one connection), #of Parcels? SPL
I& Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) O 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 PublidCommunity 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.
❑ I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (ie. 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.co.mason.wa.us.
1^.I-I I Pnrm4 Dnnkme N"aLL Re iwd 4272021
Individual Water Well
q Water well report (attached to application). Depth
106 ft
400
tN Well capacity Test(attached to application) 10 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).
Water Resource Inventory Area (WRIA)
Development within which WRIA http-1/gis co mason wa us/planning 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.
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
' q�ySU-Vi. 8/1012026
Environ. Health. Date
This form may be scanned and available for public view at www.co.masofl.Wa-US.
Peec2 oft
II'to Odgtael and F]nt tbPy wTM Ap➢amu.No.
DepaedCop Ofgmdar WATER WELL REP�5RT.
Th�xd 0opy—➢deers ceaY STATE OF W68HIIP6TOpt •P®1t No:
(I) OWNER N j ! _4k ei'eva: 1ynr Ir611C.y(2) LOCATION OF WELia capnb_Mee➢n •— _-- 1 w_--tk r
Bamdg and distance Lam aeeuan or subdivision corner C
(3) PROPOSED USE: nomtado g Itetlnddd ❑ mwdwwl❑ (10) WELL LOG:p _.. ... .
$Igatioa O Ton Wall O Olhe O Tam ad. color.
.:D aoodf�aq�uv//tetm kNa an8 afialuK q the mottt vtUM,eoa�•It
rtrahm Panaem h t ted.w d 4vft owl entw for euc?.ehango of fonnatbn.
0"W's number d will
(4) TYPE OF Ww (x man fbm and.... _.—._.—.__._ amTaarAL FROM TO: '.
Mn,New well al method:Dog ❑ Boxed 0 µ _
Deepened ❑ Cable lQ Drtvoa❑
Reoaadttloned❑ Rotatr❑ Settad ❑ 1iiwn • . _ - IS
'1 (5) DIMENSIONS- Ddmoter of well. S_Ircha P l
mnm 10ti_tl Depth ae cemyided we»_ _IOb._.sf. n
(S) CONSTRUCTION DETAn 4. ®nA R �ggy1 Pn nl
wmmw W
Caging insianedt—�_"D,—.fmm--a.-a M _206.a
Tfawadea❑ —.—"
Wemed® —"DYm.tram —.—a to.__._a
PSTlmatiOnC Yee❑. I No•®
'Type m Pertorn m tor t — ---- i
' SIZE of yeafomtlam— N.by . — )n.
pesfnmtiom from_
j --cedomtfom Lora It.to —_—
➢mtoteuam tram. a to .ft
StSeeng: ye❑ No
{ maauta tint Nam —
{ Model No —
{ Diem.--Slat else__.__Lam___—.a to ____t<.
ft
Grave! Pecked: Yta❑ No Sum of gravel:__
Gloved Dusted Ltm____—a to__ —a
Surface seal yea❑ No® To what depth? --_-- M
{ material used In aL__.
Did any draM vor.in ooamble wet? Yea❑ No❑
• Type m WAIN? De tb of sent —
1 ddethod of seaiIz strata o8 j
(7) PUMP: mmWaatwere Name._—__ —
Tfpe: _...._ .__..BP—.----
(8) WATER LEVELS: Iavd- orfee.de...una
/� dhow mean sea level... .-.—a
b SGN@ eaves--hW._..._-6 below top of wan Dotes—.. _________________________________________
Minion pantos_ 'm.per punt Iran oats . __
j Aztisbn W-W L canem➢va by__________live. etc.) —•_
{ (8) pumps TESTS: l➢afwa6°finer n f a a°'as tIwedm•Iay.t I. S rn,nry
work abated�SL111'CIC..Ted`3"comwtem_._?�.,.�,- —,fs`Z3_
Was a pump fart made? . _ ❑ No Q 1f. dr b dwham)—__—__.__
ylda: gd.nda,wm n. drwaawa aaer hm. WELL IIRILI.ER'S STATEMENT:
This well was drilled under my)urisdietion and this report is
true-to the best of my knowledge and belief.
Hemyery data Rime taken as we when mane tmata as) Iwatc ]met
j
L Tema WPM Laml' Thfl eme Walae Lmet Tin. Wrier novel (p.n.gnn.or rorporaaed (Type ar Ddnt)
__..._.__....—_ ._.._._ ._._____._._.. .....__........__.... Addmsa_._ tQa.....4. .y.3 __._..._.__
• .. Data of —__..__�__ _.._. [Sled)._______._._.._._
Bauer teL__ ^� '^ wlih�_tt.dnwdowo a[Me�_fia lWau nrB)ad
Artmian flow . ga.m.
Tc atusre of water Was o eetmical anatyals made?Y.❑ No❑ Ucanse No.__.._..__._....____......._.Date_.._........_.. ... ...de._ .
(Da2 snnrflONAL meats>e Nt�88AAY)
S H No,'UIF-OSxmA 1q .
NICHOLSON DRILLING INC.
PUMP TEST
NAME: SC CREATA9LE5 LLC DATE June 24, 2026
SITE. 781 NE TAHUYA RIVER DR TIME 900AM
TAHUYA WA 98588
WELL DEPTH UKN I Feet WELL DIAMETER r6 inches
PUMP MAKE UKN PUMP MODEL 3/4HP
TANK MAKE j TANK MODEL 81 GALLON
Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate
ow. To Down gpm to Down gpm to Down gpm
Water Water Water
Static 54.0 0.0 40 92.8 38.8 660 0.0
1 59.2 52 45928 388103 720 00
2 63.8 9.8 50 92.6 38.8 760 0.0
3 677 13? 60 92.6 388 10.3 840 00
4 714 174 70 92.8 38.8 900 00
5 744 2O4 10.3 80 928 38.6 10.3 960 00
6 767 22? 90 0O 1020 0.0
7 79.1 25.1 100 0.0 1080 0.0
8 80.8 26.8 120 00 1140 0.0
9 82.4 284 150 00 1200 00
10 84.0 30O 103 180 0O 1260 0.0
11 84.8 30.8 210 00 1320 0.0
12 862 32.2 240 0.0 1380 00
13 86.9 32.5 270 0.0 1440 00
14 877 337 300 0.0 1500 0O
15 884 344 10.5 360 0.0 1560 00
20 90,7 36? 420 0.0 1620 O0
25 91.8 378 480 00 1680 00
30 92.4 38.4 10,3 540 0.0 1740 0.0
35 92,7 38.7 600 0.0 1800 0.0
RECOVERY
Time Depth Draw IM
h Draw Time Depth Draw
to Down Down to Down
Water r Water
1 856 31.6 5602 45 0O
2 80.5 26.5 556 16 50 0O
3 758 218 .3 0.3 60 0.0
4 721 181 535 -0.5 70 0.0
5 685 14.5 529 -11 80 0.0
6 655 11.5 .8 -32 90 0.0
7 63O 9.0 0 -4O 100 0.0
8 61.0 7.0 .5 -4.5 120 0.0
9 59.2 52 495 -0.5 150 0.0
10 575 35 0.0 180 0O
Comments:
SIGNED BY:
Christopher Chilton-Pump Supervisor
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap
26276 Twelve Trees Ln NW, Ste. C
�— _wxea e.ae.l.n=e marr=rs Poulsbo, WA 98370
Phone: (360)779-5141
wwwspectra-lab.corn
spectra-lab corn
Spectra Labs - Kitsap, LLC (Poulsbo) received samples for Nicholson Drilling Inc. on Thursday. June 25,
2026 at 1:40 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
Hydrant 06/24/2026 9:30
?[3336-0I Samuel Fry Y
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
Attachments
01)
This report is issued solely for the use of the person or company to whom 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 he reproduced
except in full, without prior express written approval by Spectra laboratories.
06/30/2026 Page I if I
262,6 Twelve
Trees LR NW
Poulsbo.WA • SPECTRA Laboratories-Kitsup
98370 -- m+uee nauen
(360)7'/9-5141 COLIFORM BACTERIA ANALYSIS FORM
--Date Semple cdC teo1d fl e sample count'
��z � u Coaced ®aMI
Type
oa_n" only
yone �
Type N Water System check anyone boAJ
Cl GroupA ❑GrcupB 9JOther_____
Group Aerd Group B Systems-Provide from Wafer Fadlities Inventory(WFI):
DM
System Name:
Contact Person:
Oat'Phone: - Cell Ftmne:
Emeil: ----R .Phone.
Sera reswm n:IFt E hS su R7.08GNPAsi LSO LINrYlA(i�YMY.menlewgol"roast —�
ail --CCHICTONtUC POLSONORR1lNti GMAJL,COCCMMM — —
SAMPLE INFORMATION
9amPle aolleetedMlnameD
Specife locafan whore Semple collecrod. Specid NSWcBons or cammenm:
Type of Sample(died only one bop _ —~
I El Routine Dtsblbulbn SampIa(AIP) 2.❑ Repeat Sample(NP)
Chlorinated:Yes No (from Malibu onasalem enarumw.muunal
Chlonne Residual:Toby Free._ UnsafsWdoryroufnebbnumbec
3.Ground Water Rule Source Sample —————
Unsatsbderyroufnemtlectdate:
S ________
Chbdnabd.Yes_No_
E Triggered(NP) Chbdea Residual.Total_Free_
❑Assessment(NP)
4.Surface or 0V4 flaw Source Water Sample(Enumemtlon)
❑ E.coh ❑Fecal Fib red r.. N+_I S
68 samma couened m hmrmadoa Dam
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Uncepsfadory Tobl Collbrm Pres.nt and selabobry
❑Ecoipmaenl ❑Ecobabsoni
Baceriat penalty Results:Total GWllom onll00ml.E.co6_mpM100ml.
Feel CAlifmm_-_—cluli00ml.
Replacement Sample Requlrs: 0 TNTC ❑Sample too old
❑ Sampe Vobme ❑Damaged Container ❑_.
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