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HomeMy WebLinkAboutWAT2026-00181 - WAT Application - 9/11/2026 WAT -- MASO N COU NTY 415 N.6a'Street Shelton,WA 98584 t 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 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 of Applicant: kk((tP i ,nLs�( H` O4 '-' Date: s/ir[Z. Mailing Address: .p��i3Glc �2oSFf� W,1t,t w-9 5* Phone: 3Gt 2-FO 22- i Parcel Number: 'ZO Z'i 7-7 ~ 9®A-3Z Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ® Building permit, c9D bDD connections) O Division of land: I l Individual water source(one connection), #of Parcels? SPL 1 Well O Boundary line adjustment ❑ Spring/surface water O ❑ 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 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. ❑ 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 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.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Pagel of2 Group B Water Systems 0 Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth der ft. ❑ Well capacity Test(attached to application) 3 n gpm >400 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. wct0 I� $u 4t t4ec C ❑ Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface 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 36.70A 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: 9/11/2026 Environ. Health: `lrr Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER WELL REPORT _ ca- Noticeol'IntentNo. WE62568 ECOLOGY Type of Work: Unique Ecology Well ID Tag No, B N 08 . ate rat Nngtc rr IN Construction Site Well Name(if more than one tell): D Dccomntissioo r Original Installation NO1 No. Water Right Pernnat/c ertificnte Na. Proposed Use: l Domestic O industrial ; N11miclixil O Dewatering O Irrigation O Test\yell Other•_,,, Property Owner Norte Bill and JanLat McAurnal Well Street Address 0 E Crestview Drive Cottstrttct oo Type: Method: II New well p Alteration p Driven O Jetted O Cable Toot t:ity Shelton County Mason D Deepening 7 Other Y Dug R Air- G Mutt-Rotary Tai Parcel No. S2022 77-90032 Dintettsfons: Diameter of boring,6_ _ in..to 164 tt. ft Was a variance upttroverl 1'or this well? O Ye C No Depth ofeontpletedwell 164 Construction Details: Nall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded.Thread i p 6 ut" t 1 8 159 ' 1 0 I I 0 Location(see instructions on page 2); Cl W WM or D EWM G 1 in. rt. D I D 0 i Cl © i D irt. irt, p 1 p p 1 CJ NE A-Y4 of the 5E �4,•Section 22 Township 2ON Rapge 3W p i p _ in, Irt, .p ( D D l p Latitude(Example;47.12345) 47,21237 _.__ _._ Pekfuratlnas:Tp des Na Typo ol'perfarnturYracd Lnttgitttde(l xum,ple:-120.12345)_123.O ?50 No.ofperforations Size ofperfomtions in.by in. Driller r a Log7Constritction or Decommission Procedure Perforated$ran•,,,,,,•„ ft,to ft,below ground sttrtaee Formation:Describe by color;character,size of material and structure,and the kind and "attire of the material its each layer penetrated,with at least one entry for each change of Screens: G Yes 0 No 91 K-Packer : Depot 188 ft. information. Use additional sheets ifnecessary. Manufacturer'sNatne JOHNSON Type STAINLESS Model No. Material Front To Diameter 8 in, Slot size 16 in.front 189 1t.to 164 11- CLAY L(O)AM GRAVEL 0 4 Diameter_.,,,, _ in, Slotsize , its,from ft.to ft. BRLIWN CLAY 4 20 5and/k'ilter prick.l s Yes NJ No Size ofpack material ia. GRAY CLAY 20 60 Materinlsplaecd.hum u ft.to it. BLUE CLAY 60 140 Surface Seal: M Yes D No To What depth? 11. GRAVEL CLAY 140 164 Material used in seal 3/6 BENTONITE CHIP Did any shams cantata unusable water? Yes NI No Typeofwater? Depthofstntta Method of sealing strata off Ei- '( Puntp: MunuftctuvesName - Type:_�� (IL,e, ' tom/ 1-1.P• Pump intake depth:_..__ 1t, Designed flow mute: gpm Water Levels: Lanmt.stu•face elevation above mean sea level _ t1. C t} Stick-tip of top of well casing '�a .it.above ground surface v r Static water level 138 11.below toil of well cashtg Date 04)22/2026 Artesian pressure lbs.per square inch Date Artesian water is controlled by ,, (cap,valve,etc,) 1Yell'i'ests: Wass it ptttstpittg test performed? IF No 0 Yes , by whom?_______ 1✓ Yield,",•_,_gpm with„ ,ft.drawdown after_ his, Yield„•,_„„••,gpml with ff,dmawdown after his. Yield gent with •,••,,,_C.drawdown alter••• ,,his. Recovery dais(tittle-zero when pump is turned of-.water level measured from well tot)to water level) Tillie 1VnterLevel 'time WWtaterLevel Time Water Level Date ofpantping test ` " — — — Miller test . gpm With.___-ft.drawdown after___,,,hrs. Air test 30 gpm with stem set at 163 IL for 2 ha, Date 04!22/2026 Artesian flow.._.._. gptn - Temperature of water a F Was a chemical analysis made? D Ycs NI No Start Uate 04/1912026 Compietedfate 0412212026 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construetioti of this well,and its compliance with all Washington well. constriction standards.Materials used anti the information reported above are true to my best knowledge and belief, 0 Driller O Trainee C Pl-';—PrintNatne ROBERT LAYMON Urillin>eout nn AQVANCED DRILLING LLC sir nature Add.rsss 11530 SCHOOL LAND RQ SW LicenseNo,2588 City,state,zip ROCHESTER WA 98679 IF TRAINEE:S ousor's license No, Contractor's s)onsor's Si nature Ise istrattion No.ADVANDL804OL Date 04/23/2026 ECY 050-1-20(Rev 08/19)U';'on need this clocnmerrl in an allerrrr k'/O1 nxht,please call 1110 li'cuer Resent ces Pr•agranh a!360-907-6$72. Persons with hearing los:r can call 71/for lI'ashin,Ian/ielrrl•,5er•rice. Persons tr/lh a speech c/isabiliiv can call 877-833.6341. WATER WELL REPORT O Notice arintnnt Nn. wi=sz sli ECOLOGY Unique Ecology Well ID T tg No BPN 008 Typo of Work: 5:atr:at Vashinutc n L7 Goastnta Jinn Site WeUI Norm( more than one Well;): U DDecommission O.rigluai instuilution NOl No. Water Right Pemti(iCerliticate,No. l'ropusectitae: 11 Domestic C]LaJwtikai 1Yluuicip3l Property Owner Name Bill an(i Janet Metunittl CI Drnvatering Cl irrigation Cl Test Welt M ________________ Well 51rce1 Atlilrc (1 E Crestview Drive coltxttuctioa Type: Method: �� G•1 New well 0 Attention C fives 12 Jelled 1]Cable'tiol City Shallot) County Mason 0Deepening C)Mier W Dug l Air- 12 Mud-Rotary Cax Parent Ito. 32022-77-90032 Il( tcttsi!insr Llrrtxtcrofhurhig: _ __in.,to 184 [l. Wttsttvonunct riplaiu ed Irthis tve.11 O Yes E No Dept l ofeompieteriwwell 164 g. c onsiructiou maittist Will Ifycs,whut was the varhtnee Cue? Caking Liner Diameter hr rm To 'lfiiekuess Steel PVC Welded-Tlnead I 121 L._ia. •0 189 25 in. t 1 U 151 1 O 1 oration(see instructions on page 2)" RI_W WM oi•U EWM U 1 U _m.in. - in. U 1 U C0 1 0 NE +r of the S s<;5cct"too 22 Tousiship 20N Runge W 12 12] ._in• ,,.. in. : 1 U: U 1 C3 I e I itt. * _� �in. t Q 0 1 13 Latitude(1'e-unple:47.12;345)47.21237 Longitude('Cxtintplc:-t20,l234i) =123.03750 Perforations., Cl Yes- l No Type ottrerfwntor used No ofperibratim>S Size ofperlitnititans ons in.try in. Drsler's Log(Canstt uctlan or►7ecomniissinn Procedure Perfottdell front -A.trs ft.below gruuu ce I orrtratiaa,Desrribc by color.character size ofunterial and slnicture inn tin kind and :tarmac ofrhe ttuucriul in cacti la}erpeaetnued, vftlint least one entry iorcach change of Scrvel s: 151 Yes 13 No 11 K•packcr rr�'»-}` Depth 138 il, information,tlseaddniotiutshceia If access aty. Miinulucturer'SName JOHNSON (Material .['colts TO Typo STAINLESS Model Nu. Di anictcr in, Slot size 16 iii front i 14 it S9 ft,to 6 . CLAY LOAM GRAVEL 0 4 Diameter in. Slot sire__,,,,,,_, in.tram_.__.._ft.to 1t. BROWN CLAY 4 20 GRAY CLAY 20 60 SesudiVtlter park:C]Yen 151 No Sire of park mstedal _ _ in. BLUE CLAY 60 140 Maie.rmisplaced frvut,.,,__„-f1.to ft, —__ GRAVEL CLAY 140 164 Suri}ree Seal: 151 Yes Cl No To what depth:'-It. ________ Materioluscd iii seal 318 SENTONf'IE ct-lIP Dirt any>3irnm corihiiti unusable avatct? Yes 151 No typo ol'avnter" Dcptit ufstrata Method ofscalutg sunta off Pinup:Munufacituer`sNanie__ , Type: 11.It: ___ frump intake wtepth: 11. Designed flow sate: gpua Water bevels:Land•suriirce eievationabove mans sea level_, it. Stick-np of top of well casingg 1.6 IL above groundsnrlitce Static water lectil 138 ft.below top ofweil casing Date 04(2212020 Artesian pressure_-,,,`_His.per square inch Dale , Artesian water is euntroIled bye ,(cap.valve.etc.) Well Tcstst lgritsitpntupinptcstperfonuut"151 No U Yes t='J by whom?_, _ __ Yield-ppm wilh,w, ,fl.dia ikewn after -_._hip. Yield ,,,,gpm with,_ __6.dinwduwn after.,,, ,,tan. Yield gem with _ tilrawdatvualler bra. kecarery data{diem zc n when punip is tunisd Oar--avatar leant measarcct frumm di top to water iewa:t) little WuterLevel 'lime Water Lewl Thuc Witter Level Date ofinuuplag test hailer tent gpmWith 11:rimwdowtr after bra. a Air test ;fO ppm with stein set at 163 tl.for 2 brs. ;IDate 04/2212026 Artesian Row #pill Temp,ntturcofrvatcr_ _ °lr Wasa etrunisul arttl}^to titadc7 U Yes IS]No Start Tate 0411912026 c rttnplr rata D tIe 0412212(326 W>LI.CONSTRUCTION CE.RTIFIiC. VION: I connirtteted andlor accept tuspousibility for construction of this welt,and its-compliance wills all Washington wvell construction siwidards.Nlittenials used and the information reported above are-true to my best knowledge and belief. E I3ritter O Trainee G M.—Print Nunse ROBERT LAYMON f rillitt't om an•ADVANCED DRILLING LLG Sigh tttttt Address 11530 SCHOOL I-AND RD SW Ltuenst;No.2588 Lily,State.Zit ROCHESTER WA 98579 IIM^TRAINEE:Sponsor's License No. C;ontravtor's Sponsor's Signature tic istrtttion Nia.ADVANDL804D1. Date O4123/2026 ECY 050-1-20(Rev 08/19)IJ yotr aced this tiorianeill in an etlJcr na1e,%rJrnrrrt,plirasrz call the If titer Rnrocsrres 1'i usfrarn at 360.407-687,?, t'e:sonx with heaa ii,g&see rwar call 711 far II'aslungiwi liahtp 5errh:rs I'ersanc i:+lJli a xlreeeh tlierrlillitr can c<r1T 1 f7 N 3-fr 7.11. TThurston County Environmental Health 412 Lilly Rd NE 4 Olympia,WA 98506 Thurston County Environmental Health 360 867-2631 412 Lilly Rd NE 6 Olympia,WA 98506 URSTON COUNTY gN a z l 360 867-2631 COLIFORM BACTERIA ANALYSIS THURSTON COUNTY Date Sample Collected Time Sample County j COLIFORM BACTERIA ANALYSIS ' f ' Collected AM 4A'≤ /1.) Date Sample Collected Time Sample County Collected loath Day Year — PM 1 ( ( I 2(1• ®AM MA,6 ) 1 l /pe of Water System(check only one box) ll Private Household Month Day Year 0 PM ❑Group A ❑Group B ❑Other Type of Water System(check only one box) Private Household roup A and Group B Systems—Provide from Water Facilities Inventory(WFI): El Group A ❑Group B 0 Other )# Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ystem Name: ID# System Name: ontact Person: ay Phone:( ) Cell Phone:( ) Contact Person: -mail: Eve.Phone:( ) Day Phone:( ) Cell Phone: end results to:(Print full name,address and zip code or email address) E-mail: Eve.Phone:( ) Send results to:(Print full name,address and zip code or email address) SAMPLE INFORMATION -- — ------ ;ample collected by(name): SAMPLE INFORMATION i F" Sample collected by(name). I iC � ;peciflc location or address where sample collected: Speciall,insfyctions or comments: ) A l�i# it/ — F'� 4 I ,/y � ! t '! I s `i ; 'Specific location or address where sample collected: Special instructions or comments: f e of Sam le(must check onl one box of#1 through#4 listed below) i,a o�t ' iaa,':; t.:''Y) ' rte.. I.El Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Type of Sample(must check only one box of#1 through#4 listed below) Chlorinated:Yes No ❑Distribution System 4.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorine Residual:Total__Free— Chlorinated:Yes No 1. Chlorinated:Yes No ❑Distribution System 3.Raw Water Source Sample Chlorine Residual:Total_Free— ! Chlorine Residual:Total—Free_ Chlorinated:Yes No ❑E.coil—GWR(AlP) 3.Raw Water Source Sample Chlorine Residual:Total—Free— ❑Fecal—surface,Owl,springs(numeration) Unsatisfactory routine lab number: ❑E.coil—GWR(AIP) Filtered:Yes No ❑Fecal—Surface,owl,springs(numeration) Unsatisfactory routine lab number: ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: Filtered:Yes No _—_ _ ❑Other 1 1 ❑Assessment Monitoring(Alp) Un5#fsfactory routine collect date: S ElOther / I i 4.tgSample Collected for Information Only S Investigative Construction/Repairs Other 4.[ Sample Collected for Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Investigative Construction/Repairs Other El Unsatisfactory Total Coliform Present and �J Satisfactory LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Coliform detected El E.coli present ❑E.coli absent ❑Unsatisfactory Total Coliform Present and Satisfactory Replacement Sample Required: ❑E.coli present ❑E.coli absent No oliform detected ❑Sample too old(>30 hours) ❑TNTC ❑ Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform 1100m1. E.coli 1100ml. Fecal Coliform /100m1 Enterococci /100 ml. Bacterial Density Results:Total Coliform 1100m1. E.coli 1100ml. Method CodeJ tSM 9223Q ❑SM 9222D Date and Time Receive )— Fecal Coliform I100ml Enterococci 1100 ml. El SM 92156 ❑Enterolerl® ; : '?-. P Method Code' SM 9223B ❑SM 9222D Date and Time Received: Date and Time Analyzed: 3 ? f , Date Reported: Y?'( ' •)_k El 5M 9215B ❑Enterolert® . �, ' - O Sample Number(DOH number plus five digits) ( ® Date and Time Analyzed: ( Date Reported: Lab Use Only: C �3 7�.::_L/ 0 8 0 t Q t ' � Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 t i. DOH Form#331-319(revised 11123) , � DOH Form#331-319(rev is ed 11/23)