HomeMy WebLinkAboutWAT2023-00086 - WAT Application - 4/27/2023^gym
WAT 2�,- 0008(.p
MASON COUNTY
ENVIRONMENT COMMUNITY DEVELOPMENT
HEALTHPermit Assistance Center,Building,Planning
415 N 61''Street, Bldg 8, Shelton WA 98584. 11 IC)
Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 Elma: (36ktWl.
FAX(360)427-7787 ��1--
Application for Determination of Water Adequacy$ 2 , 2023
Street
Instructions 15 J. A\der
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 Va7/ -2-)
Name on Applicant: JL,'t �9 rU„�. Date:
Mailing Address: Zyp E LA-v ,,.Ay Phone:
,S ICz- mrv, to^ 9ey;� '
Parcel Number: 9_945 f I- o co e c
Type of Water SysLeiil Reason for Application
`V Public/Community Water System (2 or more . Building permit Pj LQ s06 Pi
connections) 0 Division of land: /
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
❑ 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) C�
System box. C p2 w .0`�l c k (J
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: NU-
(write t2i✓
(write "none" for two-party)
O I am the manager of this water system. The water system has been approved for Z- services.
There are presently t =connection(s) in use. This will be the Z'` connection.
O 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 imi set by state and ocal regulation.
Signature of Water System Manager Q Date �7/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 125 2018
Individual Water Well
Water well report (attached to application). Depth `� 1 ft.
Well capacity Test (attached to application) (o gpm '8 O 0 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://gis.co.mason.wa.us/planninct 14 Y15_ 16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date c'—it O (C(
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)
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: (,� ( /
Environ. Health: 1 Date `vj/(2�
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 012
WATER WELL REPORT Start Card No. 038546
Unique Well I.D. 4 ABJ767
STATE OF WASHINGTON Water Right Permit No.
--
(1) OWNER: Name TATUK, JACK S JAN Address 2241 ATTERIHHRY RD. SEQUIN, NA 98382-
Z
(2) LOCATION OF WELL: County MASON NW 1/4 NB 1/4 Sec 32 T 21 N., R 2t/
. (2a) STREET ADDRESS OF WELL (or nearest address) 250 LA[EWAY DR., SMffi,TON
(31 PROPOSED USE: DOMESTIC =___ (10) WELL LOG
a
(41 TYPE OF WORK: Owner's Number of well Formation: Inscribe by color, character, size of material
'
_ (If more than one) and structure, and show thickness of aquifers and the kind
Method: CABLE and nature cf the material in each stratum penetrated, with
NEW WELL at least one entry for each change in formation.
. 15) DIMENSIONS: Diameter of well 6 inches FROM TO
Drilled 154 ft. Depth of completed well 151 ft. MATERIAL I(6) CONSTRUCTION DETAILS: 0 2
FOREST SOIL
_ - BROWN CLAY aGRAVEL HARD PAN 2 19 a Casing installed: 6 " Dia. from 1.5 ft. to 154 ft. GRAVEL BOULDERS 19 24
'v. WELDED " Dia. from ft. to ft. BROWN CLAY Si GRAVEL HARD PAN 24 34
" Dia. from ft. to ft. BROWN CLAY & GRAVEL 34 42
EROWN HARD PAN 42 48
BROWN SAND STONE 48 55
Perforations: NO Type of perforator used BROWN CLAY & GRAVEL SS 63
in. by in. SAND BLUE CLAY 63 78.5
perforaati
SIZE of perforationssfrom ft. to ft. BLUE CLAY 78.5 87
ons f CLAY 87 101
perforations from ft. to ft. BLUR SAND101 201
perforations from ft. to ft. BLUR CLAY
BROWN COURSE SAND & WATER 149 149
154
jScreens: NO
Manufacturer's Name
S Type Model No. I
1Diem. slot size from ft. to ft.
3 Diam. slot size from. ft. to ft. I
r
Gravel packed: YES Size of gravel PEA y
Gravel placed from 151 ft. to 154 ft. f
z
z3
Surface seal: YES To what depth? 20 ft.
iiiMaterial used in seal HHNTOITITE C X w
Did any strata contain unusable water? NO =_
3 Type of water? Depth of strata ft. 10 `i,
Method of sealing strata off CASED I
fll
s (7) PUMP: Manufacturer's Name N P
Type 1
...- - ............... I
(8) WATER LEVELS: Land-surface elevation I
above mean sea level ... ft.
/ Static level 86 ft. below top of well Date 05/10/P4
) Artesian Pressure lbs. per square inch Date 1 1
Artesian water controlled by Work started 04/28/94 Completed 05/10/94
(9) WELL TESTS: Drawdowni is amount water level is lowered below WELL
constructed and/orOR accept responsibility for con-
)5 level.
Was a pump test made? NO If yes, by whom? struction of this well, and its compliance with a
ll
) Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used
and the information reported above are true to my
knowledge and belief.
) Recovery data
0 Time Water Level Time Water Level Time Water Level NAME ARCADI:PersIA DRILLING rm, rINC�poralion) (Type or print)
,_ ADDRESS SE 70 RD
Y
Date of test / /
Bailer test 10 gal/min. 46 it. drawdown after 1 hrs. (SIGNED' / 1��i. --A License No. 0950
= ft. for hrs.'
Z Air test gal/min. w/ stem set at Date I Contractor's
) Artesian flow g.p.m.
1 Temperature of water Was a chemical analysis made? NO 1 Registration No. ARCADDIO98A1 Date 05/:2 94
)
WATER WELL REPORT DEPARTMENT Of Notice of Intent No. WE51216
ECOLOGY Unique Ecology Well ID Tag No. ABJ767
Type of Work: State of Washington _
O Construction Site Well Name(if more than one well):
❑ Decommission t= :, Original installation NOI No. Water Right Permit/Certificate No.
Propaed Use: EN Domestic 0 Industrial 0 Municipal Property Owner Name Jack Tatom
0 Dewatering 0 Irrigation 0 Test Well 0 Other
Well Street Address 250 Lakeway Drive
Construction Type: Method:
❑New well Gl Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other 0 Dug E Air- 0 Mud-Rotary Tax Parcel No. 22132-14-00090
Dimensions: Diameter of boring 6 id,no 155 ft Was a variance approved for this well? ❑Yes L1 No
Depth of completed well 154 a.
Construction Details: Wall — If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
I3 I 0 8 in 0 155 .025 in. D I ❑ DID Location(see instructions on page 2): Cil WWM or❑EWM
❑ I D in _ _ in. ❑ I ❑ ❑ I ❑ NW y,-A of the NW ''A;Section 32 Township 21N Range 2W
❑ I 0 in. _ in. D 1 ❑ 0 I 0 Latitude(Example;47.12343) 47.288475 N
❑ ► ❑ in. in. C I ❑ ❑ I ❑ 1 ongitu de(Example -120 12345) 122.952979 W
Perforations: ❑Yes GI No Type of perforator used,__
No.of perforations_ Siu of perfo slirsnT_in by in. Driller's Log/Construction or Decommission Procedure
Perforated from_ft.to_a.below ground surface Formation:Describe by color,character,size of material and structure,rid the kind and
nature of the material in each layer penetrated,with at least one entry foe each change of
Screens: ill Yes 0 No O K-Packer Depth 152 it. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Screens Material From To
Type Wee Wrapped Model No Bottom al 150 9 -bailed down to 154'
Diameter 2, Slot size.010 in.from 152 ft.to 155 ft.
Diameter Slot sire in from ft to a. Installed screen
Sand/Filter pack 0 Yes O No Size of pack material in.
Matetiala placed from ft.to_ft
Surface Seal: O Yea 0 No To what depth? 18 ft.
Material teed in seal Bentonite Chips
Did any strata contain unable water? 0 Yes ❑No
Type of water? Depth of strata
Method of scaling strata off
Pump: Manufacturer's Name Type:
I I P._ Pump intake depth:_ft. Designed flow rate:_ppm
Water Levels: Land-surface elevation above mean tea level 195 ft.
Stick-up(Atop of well casing 1 ft.above ground surface
Static water level 80.3 ft below top of well casing Date 1/20/23
Artesian pressure lbs.per square inch Dale
Artesian water is controlled by (cap.valve,etc.) —
Well Tests:
Wes a pumping sea performed? EN* 0 Yes r=:,) by whom?
Yield ppm with_ft.drawdown after_hn.
Yield__ppm with_n.drawdown.nor hr..
Yield gpm with ft.drawdown after_brs.
Recovery data(tire-zero when pump is tuned off-water level meowed from well _`___ _,
lop to water level)
Time Water Level lime Water Level Time Water Level
Date of pumping tea
Bailer test pm with_it drawdown after_tics.- _____ __
Air test 12 gpm with stem set at_a.for h rs Date
Artesian flow ppm
Temperature of water 51 °F Was a chemical analysis made? ❑Yes E No Start Date 1120/23 Completed Date 1/20/23
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.
St Driller 0 Trainee 0 PE- r sine RoperaY Phythian Drilling Company Arcadia Drilling Inc.
Signature Address PO Box 1790
License No.2053 City,State,Lip Shelton,WA 98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 1/20/23
ECY 050-1-20(Rev 09/18) ((you need thisdocumentg in any alternate format,please call the Wafer Resources Program at 360.407-6872.
F ro rr�"�i'��°' i� rll V7UI1 1�.�!WashingtonV 1 ltY��,!Service. Persons with a speech disabilitydisabilitycan ca11877�33-6341.
Printed
Printed from Mason County DMS
=• WA-r-f_R
- • MANAGEMENT
LABORATORIES INC:.
MINK
7016 eCh St E,Taoome,WA 9e404
COLJFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Semple County •
i .23 i m
o t�SOn
lb* ay Year �1 1
Type of Water System(d,edt only one box)
❑Qroup A ❑Group B. 14 OO her
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
1D$
System Name: �)eit'i' 7ct—i-
ContadPerem:Arcadia Drilling, Inc
Dey R+one:(360) 426-3395 Cell phone:( )
Brat Eve.Phone:( ) •
Send Imes tic(Priam 1u•hams.ed6ae end*code)
Arcadia Drillin , Inc
Po Bo. 1790 . Q '' ark ?at�dt��llt( .A
Shelton, WAS r�U= 98584-
SAMPLE MFORMAT1QN
Semlple colledad by(name): I pA V I l'
•
Sps�cbcetbn where sample ,ra>t e dd. Special�,ns or came*:kilfq-b� n " "m
Type of Sample(rated only one type of es r 4e from 'f §b6 below)
1.❑Routine Distribution Sample(A/P) 2❑ Repitittfeniple(A/P)
Chlorinated:Yes No (from rhbrburion sysiem eMr anal Wine)
Unsatisfactory rout)ne lab number.
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample — — —--- —
5 I I Unsatisfactory routine collect date:
l— — I
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total Free
❑Assessment (A/P)
4. Surface or GWI Raw Source Water Sample(Enumeration)
S
I❑�E..pi 0 Fecal Fared Yes_.. w_
b.�jiMpk Coleclgd for information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and ,ASatiafactary
❑Ewe present ❑E.coli absent
Bar:terel Density Results:Total Collform /100m1. E.coli /100m1.
Fecal C0110tm flOOmi. HPC— It mi.
Replacement Sample Required: ❑TNTC 0 Sample too old
• ❑ Sample Volume 0 Damaged Conta'ner ❑
Datefil s Received: tab Reterenca Number
R Tamp C r\LA method Coder e1
S aT`,1(
Dalyemteil.to DON tab Use OrWr MO 0 4R
nom
,,, a3 al?Printed F.run-� Tor “ COu y DMS
Printed from Mason County DMS
P ECE vED oo Flo
APR 21 2023 ENVIRONMENTAL
615 W. Alder Street 1458 MA CO WA
TPTOM #186317 Rec Fee: $204.50 Pages: 2
Return To II MITI III DII IIIIIII IIII II II II III I IIIII IIIIIl I I III I IIIII III 1II
c gFc Tot 0 r.,
240 E �-v kc41k, Or
Grantor(s): (1) � CY1- , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) TR 8 OF GOVT LOT 2 S32 - (Z Z
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2 2 1 3 2 _ 1 4 _ 0 0 0 8 0
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the undersigned grantor(s), hereby place this notice on record that the described real
estate situated in Mason County, State of Washington is subject to water use restrictions and
conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 14
Maximum Annual Average Gallons Per Day: 950 gallons
Dated on this 2 7 day of April , 20 2-3.
Signature of Grantor(s):
(1) 9.14jU - cL , (2)
State of Washington )
County of Mason
Page 1 of 2
I,the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this.2lt`` day of ty(� 1 , 20,a; ,
sc 4r k\C\ ', "1 E-n', personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and yefr last above ritten.
(5:
PUBLIC My coilfiussion expires: 07-/7- c 3
\,,:z,:zy17,-,!!!!:‘,1
OF Wp
Page 2 of 2