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Home My WebLink AboutWAT2026-00205 - WAT Application - 9/15/2026 WAT 2026-00205 MASON COUNTY 4WA'Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public Health & Human Services Belfair: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. An approved building site plan must accompany this application. Part '1: Applicant/ Parcel Identification Name of Applicant: JO ( C\k '\m\\ S Date: 22•I2..tf7 Mailing Address: Pb 5YX \q\2 \ ( Phone: 3Wb"28�o -fl 5 Parcel Number: - goRo2 Type of Water System Reason for Application Public/Community Water System (2 or more Building permit onnections) ❑ Division of land: ndividual water source (one connection), #of Parcels? SPL ,f) Well El Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) El 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. See WEL2021-00025 Part 2: Water Connection Information Two party Complete the section appropriate for the type of water connection being evaluated: �Ppublic Water System Name of Water System: \'('(' Name p Water Facility Inventory(WFI) Number: Ny1 \�• (write "none"for two-party) li 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 L 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�Print Name of Water System Manager : 1\\Q Phone J(oD- Signature of Water System Manag Date -> \ _\ _ 2 3,2 24 This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report (attached to application). Depth \-I\ ft. / >400 H Well capacity Test(attached to application) 1 2 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 within last year(attach to application). 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) R 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). Reviewer's Signatures: 9/15/2026 Date Environ. Health: This form may be scanned and available for public view at www.masoncountywa.aov Page 2 of 2 WATER WELL REPORT 1 ItfiAl Notice of intent No. WE43288 ECOLOGY UniqueL'eolog 1Vell11) lag No.BNA 142 Type of Work: ;::! of :'a l,rai or -�. Construction Site Well Name(if more than one well): Decommission Oricinal installation NO!No Water Right Pcnnit:'Cctlifieatc No. Proposed lase: [$Dome tic ❑lolly vial U Municipal I Progeny Owner Name Mike&Jeannie Imus O Dcwmcrinu 0Irrigation ❑Test Well ❑Other Well Street Address NE Lakeway Dr Construction Type: Method: E New well 1 Alteration ❑Driven 0 Jetted Cable Tao C it) Belfair County Mason __,__ _ Ui Deepening U Other ❑Dug _Air- U Mud-Rotary Tax Parcel No, 22310-79-90801 Dimensions: Diamcterofhorinc 6 in..to 171 a \\''as a variance approved for this well? ❑Yes ❑No Depth of completed well 171 li, lives,what was the variance I'or? Construction Details: \\'all - ('asine Liner Diameter From 'to Thickness Steel PVC Welded'Inroad ❑ 6 in. +1 166 114 in. W O '!i I ❑ Location(see instructions on page 2): ❑\VWM or❑l?WM ❑ I ❑ ___in. in. �1 1 7 I ❑ NE %a'tf the NW 5;Section 10 Township 23N Rangc 2W ❑ in. in. J I ❑ - I _i ❑ i ❑ iiiiiii in. n. ❑ ( i_i -m 1 :7 Latitude(l:xample:47.12345)47.50549 Longitude(Example:-120. 2345) 91941 _ Perforations: O Yes rJ No Type of perfamtor used- _ __ No.ot'perforttions Size of perforations in.by in. Driller's Log/Construction of i)ecommission Procedure Perforated from_ft.to ft.below ground surface Formation:Describe by color,character,si7e of material and.structure,and the kind and nature of the material in each laser penetrated,with at least one entry fir each change of Screens: Ai Yes CU No -'K-Packer Depth 164 It. information. Use additional sheets if necessary. Slanulhcturer's Nauae Johnson Type stainless Material From To Model No. Diwneter 5 in. Slut sin'.20 in.ftont 166 11.to 171 fl. Brown till 0 135 Diameter_ in. Slot size_ in.from-it.w_,,,,,11. Cemented Sand&gravel with water 135 166 Sand and gravel with water 166 171 Sand/Filter puck:U Yes ❑No Size of pack material in. Materials placed from ff.to ft. Surface Seal: Al Yes ❑No To what depot?25 fl. -- — Material used in seal bentonile — Did any strata contain unusable water? U Yes LI No — Type ofwnterr __ Depth tofstrata Method of scaling strata off_ Pump: Manufacturer's Name 9rundfos Type:sub H.P. 1 Pump intake depth:160 tt. Designed flow rate: 12 gpm \Pater Levels: hod-solace elewatian above mean sea level fl. Stick-up of top of well casing ti.above Ground surface --- Static water level 133 II.below top of iscll cosine Date — .\rtesian pressure_ins.per square inch Date Artesian water is controlled by trap,valve,etc.) \Yell'Fests: Was a pumping test performed' ❑No ❑Yes ^, by whom? Yield gpnt with ft.drawdown after lirs. Yield_gpnt with_ft.drawdown after hrs. Yield spin with_II.drawdown after hr.,. Recovery data(tittle=zero when pump is turned oil'—water la\el measured from well lop to seater level! Time Water Level Time Wale.Level Time Watert.eef Date of pumping test Bailer test 16 gpm with 16 It.drnadown taller L. .,lies.1 --— Air test _gpm with stem set m_fl.for tins. r Date Artesian flow_gpm J — Tentpemtnre of water_"F Was a chemical aumlysL,tirade'.' ❑Yes U No Start Date 12/20/21 Completed Date 1/30/22 WELL CONSTRUCTION CERTIFICATION: I constructed mtd%or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported aboec are true to my best knowledge and belief. Q Driller❑Trainee❑P Print.'ame Mike Davis Drilling C ontpam Davis Drilling Si nature Address 340 NE Davis Farm Rd License No?t7 ! City.State,Zip Belfair WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI1 10OA Date JAN 2022 ECY(ISO-1-20(Rev 115 19)If van r,-en this dot•unrant in an aht'r'natt'larnrat,please cull the'lfiut'r Rrsaurees•Praagrian ai i60-407.6,472. Persons urith/tr'w'ing loss can-till 7/1 liar ff iailriugiorr Rckat•.S,,-ricer Pa'isauc frith it speech disabilih taut ca/I.'177.833-634/. NICHOLSON DRILLING INC. PUMP TEST NAME: JEANNIE IMUS DATE May 13,2026 SITE: 71 NE LAKEWAY DR NORTH TIME 11:00 AM BELFAIR WA 98528 WELL DEPTH 171 Feet WELL DIAMETER I .6 linches PUMP MAKE IGRUNDFOS PUMP MODEL 10S07-12 TANK MAKE TANK MODEL 120 Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate 1100AM To Down gpm to Down gpm to Down gpm Water Water Water Static 129.0 0.0 40 142.8 13.8 660 0.0 1 134.7 5.7 45 . 142.8 13.8 12.0 720 0.0 2 137.5 8.5 50 142.8 13.8 780 0.0 3 139.7 10.7 60 142.8 13.8 12.0 840 0.0 4 140.9 11.9 70 142.8 13.8 900 0.0 5 141.6 12.6 12.0 80 0.0 960 0,0 6 142.0 13.0 90 0.0 1020 0.0 7 142.3 13.3 100 0.0 1080 0.0 8 142.5 13.5 120 0.0 1140 0.0 9 142.6 13.6 150 0.0 1200 0.0 10 142.7 13.7 12.0 180 0.0 1260 0.0 11 142.7 13.7 210 0.0 1320 0.0 12 142.7 13.7 240 0.0 1380 0.0 13 142.7 13.7 270 0.0 1440 0.0 14 142.8 13,8 300 0,0 1500 0.0 15 142.8 13,8 12.0 360 0.0 1560 0.0 20 142.8 13.8 420 0.0 1620 0.0 25 142.8 13.8 480 0.0 1680 0.0 30 142.8 13,8 12.0 540 0,0 1740 0.0 35 142,8 13.8 600 0.0 1800 0.0 RECOVERY Time Depth Draw Time Depth Draw Time Depth Draw to Down to Down to Down Water Water Water 1 136,6 7.6 11 0.0 45 0.0 2 133,2 4,2 12 0.0 50 0.0 3 131.1 2.1 13 0.0 60 0.0 4 130.1 1.1 14 0.0 70 0.0 5 129.6 0.6 15 0.0 80 0.0 6 129.3 0,3 20 0.0 90 0.0 7 129.2 0,2 25 0.0 100 0.0 8 129.1 0.1 30 0.0 120 0.0 9 129.0 0.0 35 0.0 150 0.0 10 0.0 40 0.0 180 0.0 Comments: SIGNED BY: Christopher Chilton-Pump Supervisor Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW, Ste. C ...Where experience matters Poulsbo,WA 98370 Phone: (360) 779-5141 www.spectra-lab.com www.spectra-lab.com Spectra Labs - Kitsap,LLC (Poulsbo) received samples for Raven Imus on Thursday, April 30, 2026 at 3:10 am. 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 261679-01 Imus Well 21 NE Lakewazy Dr Source 04/30/2026 5:15 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 be reproduced except in full,without prior express written approval by Spectra Laboratories. 05/04/2026 Page 1 of 1 26276 Twelve Trees LnNW Ste.C SPECTRA Lahoratories Kitsap Poidsbo,WA .,.Where ea erience mailerz (360)779-5141 0 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 1 'SD!W 2 r^ Collected rasb^ �YJ . 15 Month Day Year ❑PM Type of Water System(check only one box) ❑Group A ❑Group B ( '0lher Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name:\f.:s t j\\ Contact Person: cs.ies\ j Day Phone: i Cell Phone: 3� — 5 Email: '{(AVM a't`flk'Y1tr) 't1G,1 (L Send resu lts to::(Print to name,address and zip code V0 SAMPLE INFORMATION Sample collected by(name): c (}} \yy Sp�ifi ,location where sa�mpl e collected: Special Instructions or comments: i b2\ j\4QJN C4N. 2-& �C��Ce Type of Sample(check only one box) 1.❑Routine Distribution Sample(AIP) 2.0 Repeat Sample(AIP) Chlorinated: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 1 I Chlorinated:Yes No ❑Triggered (AIP) Chlorine Residual:Total_Free_ ❑Assessment(A/P) 4.Surface or GWI Raw Source Water Sample(Enumeration) LS I I ❑ E.Coll ❑Fecal Filtered Yes_No_ 5. Sample Collected for Information Ony: XPr7�ate Residence ❑Constnictia&Repairs LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and satisfactory ❑E,collpresent ❑Ecoliabsent Bacterial Density Results:Total Coliform mpn110om1.Ecoli mpn1100ml. FecalColifonn cfu1100ml. HPC chill ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ Dateftma R 2\ Lab Referenc� utt�bey, Receipt Temp Ce:Z> Method Cade'SM9223B T-COUNT(SM9222D iNs repot is Owed sdeltaihe use of the person amrreann to Dale In: Date Out: whore's,eddreaed.Myuee,eoWN adsclowe other tunlythe hterded reopienl IsurOwcsued a lno have rxaved Dos repw h Q• tera,pleasereo0rM teadtehr.TOwIOO a[360'779.5141 er0 de6eoy[his repot promptly. OOH Loh—sample# a n Theta resetz rdde cello the Irv,tested vd the ea144e les 010- -- «o'hM byCw laborHay,Tris report shat nolbo roprob�cM escept ivkth vdtqulprieeesFesf writer epprwalay Spectra habeN ec. Doll Fam#731-319(erbeeve 06/I7)