HomeMy WebLinkAboutWAT2026-00182 - WAT Application - 8/31/2026 (2) WAT 2026-00182
X113 N.6"'Street
MASON COUNTY Shelton.WA 98584
� COMMUNITY SERVICES Shelton: 360-127-9670.Ext.X100
Belfair: 360-275-4467,Ext.X100
Building,Planning,Environmental Health,Community Health Ehna: 360-182-5269,Ext.400
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: April Roulst Date: 08/31/2026
Mailing Address: 561 E Cronquist Rd Phone:
Parcel Number: 12232-10-92150
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0i Building permit
connections) 0 Division of land:
0 Individual water source (one connection), #of Parcels? SPL
13 Well 0 Boundary line adjustment
0 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
,T:EH Forms Drinking Water Revised 4 4 2018
Individual Water Well
II Water well report (attached to application). Depth 126 ft.
EI Well capacity Test (attached to application) 25 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.
® Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://,qis.co.mason.wa.us/planning 14_ 15 1622
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)
ICJ 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).
Reviewer's Signatures:
�5 rJ /L 8/31/2026
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT
CURRENT
Original&I"r copy—Ecology,2n°copy—owner,3rs copy—driller Notice of Intent No. W359578 i 'i
ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. 197 BAR
Z Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION
Notice of Intent Number Property Owner Name Chris Ryan
PROPOSED USE: Z Domestic ❑ Industrial ❑ Municipal Well Street Address 561 E Cronquist Raod
❑ DeWater ❑ Irrigation 0 Test Well ❑ Other
City Allyn County Mason
TYPE OF WORK: Owner's number of well(if more than one)
Z New well ❑ Reconditioned Method:❑ Dug ❑ Bored ❑ Driven Location se1/4-1/4 nwl/4 Sec 32 Twn 22n R1 EwM ❑
❑ Deepened Z Cable ❑ Rotary ❑ Jetted (s,to r Still REQUIRED) Or
DIMENSIONS. Diameter of well 6 inches,drilled 126 ft, t�'64'St
Depth of completed well 126ft.
CONSTRUCTION DETAILS Lat/Long Lat Deg 122. Lat Min/Sec 827
Casing Z Welded 6" Diana.from +1 ft.to 121 f, Long Deg 47 Long Min/Sec .354
Installed: ❑ Linerinstalled " Diem,from f1.to ft. Tax Parcel No.(Required)1 2232-1 0-921 50
❑ Threaded Diam.From fl.to ft.
Perforations: 0 Yes ( No
CONSTRUCTION OR llISGOM1lb1lSS10N PROCEDURE
Type of perforator used I'ormatwn Describe hp cool,character.size of material and niructure.and the kind and
a ST7F of peril in.by_,_in.and no.of peril_from ft.to ft. nature of the mutcriak in each straum nr ps. ctrated ssith at least one cutr} lix each change
8. Scrrcr�: ® Yes ❑ No ofiufo[matins (LIS@A]IDI MATERIALN I SIIlili'I h II NCCIISS 1RY
0 };-Pac LceaUuu 121
DRUM TO
Manufacturer's Name Johnson
Brown Sandy Loam 0 3
Type Stainless wire Model No. Brown Glacial sediment 3 21
Diem.5 slot size 20 from 121 ft.to 126 ft.
} Gray clay with gravels 21 42
0 Diam. Slot size from ft.to ft.
Brown sand with gravels 42 70
o Gravel/Filter packed: ❑ Yes Z No Size of gravel/sand
4- Brown sandy clay silty 70 105
Materials placed from ft.to ft. Brown sand&Gravel/water 105 125
Surface Seal: Z Yes 0 No To what depth?1811.
~ Material used in seal Bentonfte Chips
Did any strata contain unusable water? ❑ Yes ® No
Type of water? Depth of strata
d Method of sealing strata oft'
a PL'MI': Manutacturcr'sName Franklin
Type:Submersible H.P. 1.0
s
} WATER LEVELS: land-surface elevation above mean sea level It.
Stacie level 64 Cr below top of well Date 5/18/18
3 Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
O
Z WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump test made? ❑ Yes Z No If yes,by whom?
Yield: gal./min.with ft.drawdown after hrs.
° Yield: gal/min.with�'�'ft.drawdown after his.
� m
w Yield: gal./min,with ft.drawdown after hrs.
Recovery data(time taken as zero when pwnp turned of)(water level nrasaed from
well top to water level)
Time Water Level Time Water Level Time Water Level
t
a
a
a
Date of test
Bailer test 25 gal.Fmin.with 14 f,drawdown after 4 hrs.
Airiest gal./min.with stem set at ft.for bra.
Artesian now R.p.m. Date Start Date 5/4.118 Completed Date 5/18/18
Temperature of water Was a chemical analysis made? ❑ Yes Z No
WELL CONSTRUCTION CERTIFICATION: I constructed 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.
Drilling Company _ KNAPP DRILLING INC.
Driller fl Engineer[]Trainee Name(Fiim) I)\vane II Knapp Address E 50 Lesaca Dr
Drilleii1 nninecr'I'rainee Signature City,State,Zip Shelton Wa.98584
Driller or trainee License No, 17(i(s
ii "tic vNi;:d-ini)ier s i,ieensc No: Contractor's
Driller's Signature: . - Registration No. KNAPPDI952B1 Date 5/33/18
L-CY 050-1-20(Rev 02110h 1/you need this ilocronr'nt in anal root: rn-ma1,please call the Ii rilei'Resources Program<rt_G0-107-0872.
Prrsv,rts aidh hcarirr,r hiss cart r rdl 71/Ii�r If ir,/rint;ton Rehr',Service, Persons sr!!,a speech disuhi/ity corn call S7.7-833-6341.
26276 Twelve
Trees Ln NW
Ste.C 1 SPECTRA Laboratories Kitsap
Poulsbo,WA
98370 ...Where exerience matters
(360)779-5141 j COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
I30I d Collected
Q t
Month Day Year 1 : 0 D l�PM
Type of Water System(check onI one box)
❑Group A ther
Group A and Group B Systems—Provide from Water Fa lilies Inventory(WFI):
ID#
System Name: Pnk1fl1D ".t_Q_`
Contact Person: ' &_Day Phone: r� �7l Cell Phone:
Email: ( / ≤/fr .t
Send results to: Pi n me ad as ani ode
6 4_ -61 3
SAMPLE INFORMATION
Sample collected by(name): ii r`f Q�t S�
L l
Specific location where sample collected: Special instructions or comments:
56/ 7' - ;Pd
/ (1 i1 Wa t
Type of Sample(check only one box)
P) 2.❑ Repeat Sample(AIP)
Ch orinated:Yes ❑ No. ' (from distribution system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S I I
Chlorinated:Yes No
❑T'ggered(NP) Chlorine Residual:Total_Free_
Assessment
4.Surface or GWI Raw Source Water Sample(Enumeration)
5. Sanrpse Collecieo for Information Only 2tiitvate Residence U ConstuctionlRepairs
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent
Bacterial Density Results:Total Coliform mpn/100ml.E.coli mpnl100ml.
Fecal Coliform cfu/100ml. HPC cfu/1 ml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
Date me W . Lab Reference Number
O \_\ o\
Receipt Temp C°: Method Code:
SM9( 29TOUNh1 SM9222D•Date In: Date Out: This report is issued solely foe the use of the persona company to
/� / whom is addressed.My use,copying a diecrowre dher than by the
( i7ntaded redpienl n unaNhaized.M you have received this report in
360-7795141 and
destroy this report promptly.
DOH Lab-Sample#
a These results relate a to theireps tested h and be the oduced as
010- '��\7�`(y\\l received by hothe elbce express sallexcept
approval by Spectra laboralaies.
DOH Form 8331519(effective 06117)