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HomeMy WebLinkAboutWAT2026-00164 - BLD CD Environmental Health Review - 8/7/2026 twnemisiynio.ssaac3zo-aesrin savnoomnr Eesac _ �AT 2026-00164 MASON COUNTY COMMUNITY SERVICES o ng Nanning Environmental elSTF Commonly Health 415 N 6'n Street. Bldg 8, Shelton WA 98584. Shelton: (360)427-9670 ext 400 fi Belfair. (360)2754487 ext 400 ê Elma: (360)482-5269 ext 400 FAX(380)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. M approved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name on Applicant µun.t S'r`lyt Date: �Z.(o Mailing Address ( obi TYtcfri�ir UM Phone. 3(,6) -:w[)^ 3qq I Parcel Number: 12o3031q 0() Type of Water System a P W Q) J Reason for Application Public/Community Water System (2 or more w51 Building permit AD'A BLD2026-00693 connections) 0 Division of and: ❑ 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 Rl' (�Mt Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System'. — k' V W ^ 3i=c.M Water Facility Inventory (WFI) Number. fQYIF (write"none"for two-party) I am the manager of this water system. The water system has been approved for services. There are presently J connection(s)in use. This will be the_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 (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 apfnyy twits-set by state and local regulation. Signature of Water System Manager lm S> � Date 07/27/26 This form may be scanned and available for public view at www.co.mason.wa.us. JAAEH Pmms\DriA;in,water Revised In5n01s uTcm,,yr ID:sso0C32D+291+11-B992 000D3ASESBD Individual Water Well ' + Water well report(attached to application). Depth_, _5(1) ft Well capacity Test(attached to application) spin >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 port cannot be ed by the applicant or if a well capacity test,which ht provides the stabilization otdraw-down and recovery data, must be performed by a licensed contactor. IR Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http.//qs co.masofl wa us/manning 14_15_16_22_ Water use or limitation recorded...........__.................... N/A_Yes___ WellDnlled ........... .. Date ................... Individual SpringlSurface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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) [ 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 36.10A 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: 8/7/2026 Environ. Health: tip__7 Date CSD Director: Date 21112 WATER WELL REPORT Not of Intent No WE62834 ECOLOGY q Ecology Well lD Tag No BRK183 Type or Work: .. - . Sue Well Name OF more than one sell) ❑ Deeom rvsimn d unroll mnallanon Not No Water Right Permnvicerthcate No Propwed in: T'T Donesrlc -'Indualnal —Slunicipal Pmpeo O crier Name Mary Smith De,merms -Imuotion Jua Wdl Other Wep Street Address 60IE1 - t nWav .— Cmeeaua.Type: `1+m•a' Op- Shelton Cne ty Mason reNn well -Alle ion —Dm n Clanue 1pble 1111 Deepening -Other =Dug ❑+Av- -stw Rm - Ta.Parcel No 12030-31-90084 Dlmemmm: Outnea oferr u 6 _ o 256 n Was aaenan e'approsed for this wall' 2 Yes Ni) Dapth orcomplena xah 256 n If_s Cs.as11at was me ranance[or' Cumber, n D oin: Nall Casing Liner Diameter From To Thickness Sod Pte welded Thread i Wµ31 or❑FWT1 Cn [ 6 0 2y]c_ -25 Di - •� C location see Inswcitona on page 2) _ • NE r ,oFthe S I"L9,Section 30 Tmanshlp 2QN Range 1W _m _ _ n fmde lExamPic 19 I234514].19168N ___ _____— Sr' _- _m. S C E 122 85488 W IorientiExample Ir01TJ1)_ Pmmrariom: ❑Yex i1n Tape llperrorvlr urea Dnller's Lug/Comtrunion or Demme ssian Procedure N1 of per[oral ione_ Sac or perforations_in ba_ Ito m[ re nrscnbe b\acre,charaOee tire nfcalerial and snucle, and the Lund and Porforned from 11 R.be]a,pecard'eacce a orlhe oaten,l m each layer leneaird ra, h at least one en m for each change of m yrK,m: ins h i'K-Packer b Depth 249 P. in formation Sssaadmmnalimcn—fn ecrosarq. >lanuhctmcts Nano Allo Machine WO!.k __-- F Material From To Tspe Stainless slotted Model No. Brown fine ravel) silt sand,loose,d 0 5 Diameter 5' Slot size.010 from from251 fi m 256 P. Brown fine to medium sand and round gravel, 5 oroome, sla side_ n cam _ft m_a 8 — loose,d 5o.alnnmr pack:'='yea No side olpact tnmenm_in Gra Isn brown fine to medium silty sand,round 8 llsenais placed from B m_it F graval,loose 12 Surface Smatt E Yes ❑Io To nhat depth' 18 R. Gray silty graveflysand,ordes,saturated 12 20 lmmisl media seal Bentonite chipsBrown fine to coarse gravelly sand,loose,dry 20 86 Dm an,strata contain unusable water' CVec •—to grown fine to coarse gravelly sand,dense,dry 66 F 107 1)Da ofxatetn Depth oforaia _— 107 189 Gra fine to coarse sand.loose mnbla 1f Staling mate la Light brown fine to medium silly sand,loose, 183 Pump: Mlanuh=mo-,ame Type moist 205 H P.— Pump intake depth:_f Designed Oo.mm:_ep`n Brown fare t0 medium sand,some gravel,will 205 217 V.ter Lea eta: Land-surface ek Moirti abode matt sea to el ]e3 P. Brown fine to medium gravelly and heavier , 21] Sad-up ortop ofwell ca sing 1_5 R ably a ground smmee wafer bearing 256 Static.rater Icrel 100 ft bdox top orxell easing Date 6/4/26 ne an pressure—Ibs persymm inch Dam onesn.nwter u ronlrolted b) cap.Mahe.etc) Well Teen: was.pumpngest performed, K ❑YesO by horn' m ar Yield gpith_ nwdex n hrc t Yield pmah h m_ .dowo after_._M1rs Yield _gpm rich_a daaaaonn after his 0.ecwm data(optic=zero,ben pump us timed oR-oaar Ice!measured from ref l top rn wat er le'sb Time Is Lmel Time \ ,ter inel Time Water i.nel Dam of pumping left .._ , Bailer t_arm.oh—a.Gb.dex'n after_M1rs F Air let' 20 epm,no stem sett 220 R for hm Dnn 814126 :nasal,flow open tempam 1[. 51 =r ache! of analysis vac" Uses �c1 Sort Date W4126 Completed Del 6/4/26 WELL CONSTRICTION CERTIFICATION: I constructed andlor accept asponsibi lily for constmetion of'his'sell,and Its compliance with all Washington wall consmmlmn standards.Materials used and the information repotted more are true to my best kno\dcdge and belief if Driller G Trainee[i PE—Fries Nei Gory Johnson D II n Coo m Arcadia Drilling Inc S' Address PO Sos 1]90 License No 3441 City,State Zip Shelton WA 96584 IF TRAMGE Sponsor's License No Contractor's Sponsors Signature Registration No ARCADDl098KI Dale 6/4126 FCY 030- .'O(Rea 09 I01 lI/,ou need this doe Intent en an aleennme/armor.please call the;Pater Resources Program of 36040''68'?. Persons ii u/,hearrug loan can cnfl'I[Jot 11'aslnngrwl Relay 5en'ice. Persons a nM1 a sperCLdtsabing can m11877-833-634/, Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Mary Smith Well Tag #: BRK183 Site Address: 607 E Inspiration Way,Shelton Depth: 256' Date of Test: 6/9126 Static: 180' Pump Set: 240' TIME GPM LEVEL RECOVERY 1 Min 7.5 180.9 TIME LEVEL 2 Min 7.5 181.5 1 Min 180 3 Min 7.5 181.5 4 Min 7.5 181.9 5 Min 10 181.9 6 Min 10 183 7 Min 10 183.1 8 Min 10 183.1 9 Min 10 183.1 10 Min 10 183.1 15 Min 10 183.1 20 Min 10 183.1 25 Min 10 183.1 30 Min 10 183.1 35 Min 10 183.1 40 Min 10 183.1 45 Min 10 183.1 50 Min 10 183.1 55 Min 10 183.1 1 Hr 10 183.1 1 Hr 5 Min 10 183.1 Total Gallons Pumped: 690 Gallons Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 -np of 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Dale Sample Gdixaad Time Sample County Collected Mason 06/09/2026 DAM m:d Type ofWaler System ichenh only one box) ❑Group A 0 Gronp B ©Other. ---- Group A and Grouo 8 Systems-Provide from Water Fanllpa Inventory(WFI). ID System Name Mary Smith ________________ Contact Pelson Arcadia Drilling,Inc Day Phme:(36C 1426-3395 GNI PM1one ( ) Email Eve Phone.( Send reve¢N tprint l9 nmr .afaresS aM np 000e or -in I) rrm®,ium.dnm,P tom AND lororr diadreees corn SAMPLE INFORMATION I Sample collectedby(oamerShad Specific locaan where samples collected Speoal'nseactions or comments. 5RK1S3-607 E Inspiration Way.Shelton Counts please Type of sample(sekctonIyone type of sample from types l tlltagl5 belwl) 1 ❑Routine Distrllwtion Sample(NP I 2❑ Repeat Sample(NP) 6hlormated-Yes .._N0 --. Itmnealncumnerser atler unnsal munnel _ Unsatisfactory routine lab number �3G,.md lorine Residuar.Total__Free_ Water R.I.Source Sample Unsatstactory Ovule tolled date: S Chlorinated YesNo ❑Triggered gVP) Chlorme Residual Total Free _ ❑Assessment (AiP) 4 Surface or GWl Raw Source Water Sample(Enumerahml „ l ❑E. or ❑Fecal rum r., no '��'1 5.®Sampec le ied!oe InlormMlon Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Thal Colibmt Present and 2Satiandory ❑Ecoripresent ❑Ecokabsent Bacterial Density Results:Total Colbnn<1;0 _)IOOmt. Ecdij:0 1100m1. Fecal Cdib 1100ml. Hoc ..limp. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container ❑ Dlemweaece.ed 6/10/2026 "apetenarce rvnmcer v o , D- 7, ace ,Temp c• Memaacode SM9223B Dale stpon ed 0 DON Lab Use Only. DOH Laid.Samplea 285- (p( 0 24