HomeMy WebLinkAboutWAT2023-00177 - WAT Application - 7/20/2023 a
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`` \ MASON COUNTY
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` ;NI COMMUNITY SERVICES RECE ,,rD
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Building,Planning.Environmental Health,Community Health �"
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415 N 6th Street, Bldg 8, Shelton WA 98584, JUL 2 0 2023 L•J
Shelton: (360)427-9670 ext 400 •:• Belfair (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787 615 W. Alder Street
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: Jacob Kennedy Date. 7/17/23
Mailing Address: 200 E Rasor Lane Phone: 360-265-5101
Parcel Number: 12207-75-00410
Type of Water System Reason for La-Applicatio�n,�
❑ Public/Community Water System (2 or more V Building permit oa-3-00338
connections) 0 Division of land:
V Individual water source (one connection), # of Parcels? SPL
Well 0 Boundary line adjustment
0 Spring/surface water
❑ Other(explain) 0 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)
0 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.
0 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.
J:\EH Forms\Drinking Water Revised 1,25201 R
swift . I
Individual Water Well
Water well report (attached to application). Depth Z� 1 ft.
e‹ Well capacity Test (attached to application) gpm > b°l7 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/planninq 14 5 16 22
Water use or limitation recorded N/A Yes
Well Drilled Date \6 I7-0 17____
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)
I Satisfactory Determination:
‘r
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: Date \A I ' /v r ' 3
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
•
WATER WELL REPORT -. _ ----- DEPARTMENT OF Notice of Intent No. WE53422
r - ECOLOGY Unique Ecology Well ID Tag No.BNM847
Type of Work: MINSgla state of`.ashington
i_■) Construction Site Well Name(if more than one well):
7 Decommission c' Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: !l Domestic ❑Industrial O Municipal Property Owner Name JACOB KENNY
C Dewatering C Irrigation C]Test Well 0 Other
Well Street Address 200 E RASOR LN
Construction Typc: Method:
I9 New wcU 0 Alteration 0 Driven 0 Jetted U Cable Tool City BELFAIR County.MASON
0 Deepening 0 Other U Dug E Air- ❑Mud-Rotary Tax Parcel No. 122077500410 __
Dimensions: Diameter of boring 6 in.,to 221 IL •
Was a variance approved for this well? D Yes i.]No
Depth of completed well 221 ft.
Wall yes,what was the variance for?
Construction Details: .__ ___
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
I ❑ 6 in. +1 211 .250 in. l] I ❑ RID Location(see instructions on page 2): [U]11'WM or U EWM
❑ I 0 in. in. ❑ I ❑ ❑ 1 ❑ NE V.-y.ofthe SW /,;Section 7 Tossnship 22N Range 1
❑ I ❑ in. _ in. ❑ I L] ❑ 1 17
❑ I 0 in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.407305
Longitude(Example:-120.12345) -122.857353
Perforations: Li Yes l3 No Type of perforator used --
No.of perforations Size of perforations is by in. Drillers Log/Construction or Decommission Procedure
Perforated from ft.to_ ft.below ground surface Formation:Describe by color,character,sire of material and structure,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: Li Yes [Ti No i]K-Packer Ci Depth ft. information. Use additional sheets if necessary.
Manufacturer's Name __ __ Material From To
Type STANLESS Model No.
Diameter 6 in. Slot size4 in.from 211 ft.to 221 ft. SAND&CLAY BROWN 0 195
Diameter in. Slot size in.from ft.to ft. SAND H2O BROWN 195 221
Sand/Filter pack:n Yes gl No Size of pack material in. —
Materials placed from ft_to ft. --—--
Surface Seal: LC]Yes 0 No To what depth? 20 ft.
Material used in seal BENTONITE
Did any strata contain unusable water? C Yes MI No ——Type of water? Depth of strata r—
Method of scaling strata off -------
Pump: Manufacturer's Name GOULDS Type: SUB
H.P. 1 111, Pump intake depth:215 ft. Designed flow rate: 10 gpm - —
Water Levels: Land-surface elevation above mean sea level ft
Stick-up of top of well casing 1 ft.above ground surface _—T
Static water level 185 tt below top of well casing Date —"
Artesian pressure_ lbs.per square inch Date
Artesian water is controlled by. _— (cap,valve,etc.)
Well Tests: — --r-
Was a pumping test performed? 0 No 0 Yes b by whom? --'— —__
Yield 6 gpm with 29 ft.drawdown after 4 hrs.
Yield _gpm with_ft.drawdown after hrs.
Yield gpm with_fL drawdown after hrs. _
Recovery data(time zero when pump is turned off-water level measured from well _
top to water level)
Time Water Level Time Water Level Timc Water tassel
I Date of pumping test — T
Bailer test gpm with_ft.drawdown after_hrs.
Air test gpm with stem set at ft.for hrs. Date
Artesian flow gpm
Temperature of water 'F Was a chemical analysis made? C Yes 'r No Start Date 10-11-23 Completed Date 10-20-23
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.
i Driller 0 Trainee p — e CLAYTON PITTS Drilling Company COOLWATER DRILLING,INC.
S
Signature Address 10921 NW HOLLY RD __
License No.25 _ City,State,Zip_BREMERTON WA 98312
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature _Registration No.COOLWDI941QM Date 11-9-23
ECY 050-i 20(Rev 11/13) If rou need this document in an alternate format,please call the Water Resources Program at
360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call
877-833-6341.
COOLWATER DRILLING, INC.
10921 HOLLY RD NW
BREMERTON, WA 98312
360-830-9005
COOLWDI941QM
CUSTOMER NAME DATE 11-2-23 1
JACOB KENNY
CUSTOMER ADDRESS
122077500410
TIME STATIC GPM TIME STATIC GPM
185
05 197 12 120 214 6
10 208 12 135 214 6
15 212 12 150 214 6
20 214 6 165 214 6
25 214 6 180 214 6
30 214 6 . 205 214 6
45 214 6 220 214 6
60 214 6 235 214 6
75 214 6
90 214 6
105 214 6
RECOVERY STATIC RECOVERY STATIC
TIME 214 TIME
05 _ 198 30
- 10 190 45
15 _ 196 _ 60
20 185 75
25 90
, 126276 Twelve I 1
i Treks Lc NW
Sre.0 It SPECTRA Laboratories - Kitsap
Poulsbo,WA
98370 ...where experience Iwters
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected II lime Sample County
1 2 23 1 collected q AM �
Mon YA Day Vox j + :�� Emu I 1/-34P1
Type of Water System(check only one bax)
{ ❑Group A ❑Group B ®-Other__ ___
Group A and Group B Systems-Provide from Water Facilities Inventory(WF1):
ID#
System Name:
nei co/3
Contact Person: ce,r,t L4.., r iL
Day Phone: 340 iUz.. )pp(' Cell Phone:
Email: Eve.Phone:
Send results b:(Print full nankin:rats and zP cods or small above for electronic copy of molts)
re,L w A-rri.it j4 AIL(..tt)Le. ffoTttAlt
SAMPLE INFORMATION
Sample collected by(name):
to ( wrkTEJt<
Specific location where sample collected:, Special instructions or comments:
A'2o2 CN
Type of Sample(check only one box) •
1.❑Routine Distribution Sample(A/P) i•2.❑ Repeat Sample(AR)
Chlorinated:Yes ❑ No 0 i (from distrluton system atter unsal.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free
3.Ground Water Rule Source Sample •
S I I Unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total_Free_
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) S I I r
❑ E.cob ❑Fecal Filtered Yes—No I I(
5.E Sampe Collected for Information Onty
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Conform Present and ; likSatisfact
ory
❑E.coli present ❑E.cotrabsent ! I.
Bacterial Density Results:Total Cctifonn mpnl100m1.E.co?I _—mpn/100m1.
Fecal Colifcrm _ cfu1100m1. HPC _-. chill ml.
Replacement Sample Required: 0 TNTC ❑Sample too old t
❑ Sample Volume ❑Damaged Container ❑_
it D R eired: 6?)D ' Lab Reference Number
Receipt Temp Method Code"
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DCH Ftae 4131419(satin o&?)
2199676 Mason County WA
07/18/2023 12:52:38 PM NOTCE
eRecorded #188866 RecFee: $203.50 Pages: 1
MOCK WEST
Return to:
Cheryl Mock-West
PO Box 3324
Belfair. WA 98528
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I(We),the undersigned grantor(s),hereby place this notice on record that the following described real estate situated
in Mason County.State of Washington;to wit:
OR 1. 22
Subdivision Division Lot Range Township Section
and having the Tax Parcel Number of: 1 2 2 0 7 -- 7 5 -- 0 0 4 j
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
Dated on this / day of ct.t.,/ 20 ..
Sig:tature of Grantor(s): '�t2J1,/7\ f�r��_._..•
Printed name ofGrantor(s): L 1 e! 1 Y77x LC �c�S7
Grantee: Public
State of Washington )
County of Mason )
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this
1.2 day of V ..lO ,20/2L_, `!X . NA- personally appeared
before me,who is known to be the signer of the above instrument,and acknowledged that he(she)(they)signed it.
Given,under my hand and official seal the day and year last above written.
No •Public in and for to State of Washington,
KAYU G BRYANT
Public
Notary Residing at rikWirp
Public /�� ,, ,,,1
State of washinaton My commission expires: [..dam- 10 21021 f
Commission W 21001574
My Comm,Expires Oct 10,20I4