HomeMy WebLinkAboutWAT2019-00082 - WAT Application - 4/17/2019 X WAT
MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health �.r)i )- ,/
G
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 -- Belfair. (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787
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 applicabon.
Part 1: Applicant/ Parcel Identification
Name on Applicant: << A) Date: 017,
2
Mailing Address:62,, ( ? Phone: Q"
Parcel Number. �j1 !!�2 Z, /l CC/ 0 VSZ3-V9 G " f' �
Type of Water System Reason for Application
ublic/Community Water System (2 or more �l Building permit
X
nnections) ❑ Division of land:
dividual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other (explain)
❑ 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
�-� Public Water System
Name of Water System: 17C07�d-e:.(AS-
Water Facility Inventory (WFI) Number: �J
(write "none"for two-party)
I am the manager of this w ter system. The water system has been approved for services.
There are presently Q 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.
Signature of Water System Manager ./� Date�, 2n(9
This form may be scanned and available for public view at www.co.mason.wa.us.
3:\EH Forms\Drinking Water Revised U252018
Individual Water Well
❑ Water well report(attached to application). Depth (,� ft.
❑ Well capacity Test(attached to application) qpm 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/planning 14_ 15_ 16_22_
Water use or limitation recorded................................... N/A Yes
WellDrilled ............................................................... Date
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
i -
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 6.68.04D-Determi nation 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
CSD Director: Date 2 of
WATER WELL REPORT CURRENT
VAN Original&1"copy—Ecology,211 copy—owner,3''copy—driller Notice of Intent No. W316920
DEPARTMENT OF
ECOLOGY Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No. BJT941
Stale fW,,h1,9t
® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION
Property Owner Name Carl Brownstein
Notice o Intent Number
PROPOSED USE: ® Domestic ❑ Industrial ❑ Municipal Well Street Address 2743 SE Bloomsfield Rd
❑ DeWater ❑ Irrigation ❑ Test Well ❑ Other
City Shelton County Mason
TYPE OF WORK: Owner's number of well(if more than one)
® New well ❑ Reconditioned Method:❑ Dug ❑ Bored ❑ Driven Location NE1/4-1/4 NEIA Sec 31 Twn 19n R 3W EWM ❑
❑ Deepened ® Cable ❑ Rotary ❑ Jetted (s,t,r Still REQUIRED) Or
DIMENSIONS: Diameter of well 6" inches,drilled 67 ft. wwM
Depth of completed well 67&
CONSTRUCTION DETAILS Lat/Long Lat Deg N47. Lat Min/Sec 12'30.95
Casing ® Welded 6" Diam.from +1 ft.to 61 ft. Long Deg W-123 Long Min/Sec 4'22.4.
Installed: ❑ Liner installed Diam.from ft.to ft. Tax Parcel No.(Required)31922-1 1-00010
❑ Threaded Diam.From ft.to ft.
Perforations: ❑ Yes ® No
CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and
SIZE of perfs_in.by_in.and no.of perfs from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change
Screens: ® Yes ❑ No ® K-Pac Location 60 of information. (USE ADDITIONAL SHEETS IF NECESSARY.)
Manufacturer's Name Johnson MATERIAL FROM TO
Brown Top Soil 0 1
Type Stainless wire Model No. Sandy Loam 1 4
Diam. Slot size from ft.to ft. Brown Sandy Till 4 12
Diam.5 Slot size 20 from 62 ft.to 67 ft.
Brown Silty Sand w/ClayLenses 12 44
Gravel/Filter lac packed: [I Yes ® No Size of gravel/sand Brown Sand&GravelWaterBearing 44 67
Materials placed from ft.to R.
Brown Clay 67 ->
Surface Seal: ® Yes [INo To what depth?18ft.
Material used in seal Bentonite Chips
Did any strata contain unusable water? ❑ Yes ® No
Type of water? Depth of strata
Method of sealing strata off
PUMP: Manufacturer's Name Franklin
Type:Submersible H.P. 1.25
WATER LEVELS: Land-surface elevation above mean sea level ft.
Static level 38 ft.below top of well Date 3-22-19
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump test made? ❑ Yes ® No If yes,by whom?
Yield: gal./min.with ft.drawdown after hrs.
Yield: gal./min.with_ft.drawdown after hrs.
Yield: gal./min.with_ft.drawdown after hrs.
Recovery data(time taken as zero when pump turned offl(water level measured from
well top to water level)
Time Water Level Time Water Level Time Water Level
Date of test
Bailer test 20 gal./min.with 14 ft.drawdown after 4 hrs.
Airtest gal./min.with stem set at ft.for hrs.
Artesian flow_g.p.m. Date 3-15-19 Start Date 3/11/2019 Completed Date 3/15/2019
Temperature of water Was a chemical analysis made? ❑ Yes ® 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❑Engineer❑Trainee Name(print) Dwane H Knapp Address E 50 Lesaca Dr
Driller/Engineer/Trainee Signature City,State,Zip Shelton Wa.98584
Driller or trainee License No. 1706
IF TRAINEE:Driller's License No: Contractor's
Driller's Signature: Registration No. KNAPPD1952BI Date 7/12/2018
ECY 050-1-20(Rev 02/10) Ifyou 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 ivith a speech disability can call 877-833-6341.
1786 SE Mile Hill
Port Orchard WA
w
� fiP1 CT`RA Latsorato�riea-Kitsap ww.spertra-labeom
443-784 �E
COUFORM BACTERIA ANALYSIS FORM "
s ss c�«tW r�Sampt
CardYM
IJ C1nw
Type d Waar System(d�ecic ordy o e bac}
y
CDA L +A a3 �a r JG "
-1 �-C'
441
troy A and Group 8 Systems-Provide from Wader Fadtlea tnvenb y tWFI y
System Name 1 is wPr Ti k� F" u
Day Phdte 42 - 3 Z� Ceil Phone x
_ '
Ema� Eve,Ph0r1e
SePld nlstfl4S aLC(P�d NIFi. alld Code or ✓ A ro E u � _ * � :
x
specittcaceiion,wtieresee>pa ! Speciailmindfonsarssaranents: Coliferm.Distribution System
t,lct 915/mexp .+ SlIMPUng Procedure
Step one Stop Four
1,C1 RoutMe Or bAlor Sampia taller onset routine) Avoidp�sample at" as Therwmybe same kuA o
2.Repeat Sample swivelfanets,hot and eold mixing powder in the sample bottle to
Chaomnaad:Yee p No[] ❑err System faueets(withaaiaglelever),lealryor ramova Alorine.Do eat rinse it
Chlorin$ReaMual:Toted— Free— � routMe IeD rurtd+er.
_ Sprayitkgfaueets,drinlclag out
3.Swoe Ground Water Role Samoa _ —_.—---.-- Iaanft**dtodd.dnhs,f vat-fres
s raaMemded Me: hosebihs andfauestsbelowormear sup
av elontimioatiton,while
} grmusdlerel. taYM&the sample,hold than bottle
! 0Triggered Chid tOd:Yes U-No U Step Two neartlt`botton wiWatthaadaid
0
Chlorine Paa":ToW _Fme Remmaayattaahmentsbramthe hold the top of the Opwrthtlte- fad,indeding aerators,smear, odw.Nos*unscrew thecmp.
a. Emwoeea,swwwaxs=* S waAerskosesandwatafiltersi if
0E.Col 0Fecal- ww.���.❑ rdo� goaeltoosetodisiafectthesample Im?R(iTsetthetmpdown,touch
siepriflrto.sampleoollectoa,be s�►plofthe cap thatteacbetthe
50 " prtpee"'o",' bottleorlet,a too6therim
��1'iiteto#t�shdtoroutoresiave �E
alldisinfedanit. ofthebtttdeormsidetheeaW
Un+1 Gary Tatter GaFUxm Pteaenland ld six
Hold
�e F. tit Ithebottleunderthastze imof
Replaw-S S-06 RDWWrd: water�be carefalnottolettImbottle
�Ssnpir,000kf>3Qhoursj QTNTC 0 tonc$tthaaampletap ltillthebottle
to theindicated$lline,donotallow
t tyRee ta:Tddcar*rarn aona Scar tooaa it .R;wmowC16,bottle
Sto
FuatCdpcen Obi. HPC 1�." fa:+nmthewaterllotaandseetlr�athe
Time cap.
Turnouthecoldldwatteronlyauc1 stop Ssa W
letitruavwithasteadystreamfor Complatethelabshp.Koteanptltisa
a aC "`M 2019 at leastfmmiztutu-Before aaususlaeboutmesamploeollectioa.
coliecaiag the sample,tuts&a
rvaterdovwntoatkStreamud "Step Ekkt
w -1 letthewaterrmforone Acttutothelab fiptothebottlewith
a�baa bu"oar: If$eysYstattnisehlori ztA rabberbaad.De verthesampleto
_ meataarethefceeeltlarineandnate Ceat k Aaab* l Labs as soon as
tt w.sN+a+sa irwar+q-ryd�rwre�rnr..aw.e gem. cm0a •rn+l ��3arementonthole aBp. pi7laSi�lt .
nir rm aMr prhls.sw w+li6U a�
RECEIVED
ENVIRONMENTAL APR 17 2019
HEALTH
615 W. Alder Street
Return to: 1
\C�f� m6'Bt,Jn?S AT"
2L/
8 SV�
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
l(We),the undersigned,hereby place this notice on record that the following described real estate situated in Mason
County,State of Washington;to wit: OR A�� �Z
Subdivision Division Lot Range Township Section
and having the Tax Parcel Number of:3_L? 2-Z- _L 1 -1Z 0 J Q
is subject to water use restrictions and conditions set by Washington State Serrate 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: Maximum Annual Average Gallons Per Day:
Dated on this 9 day of 20 •
Signature Signature
State of Washington )
County of Mason )
1,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this
_6 day of Agee l 2019 ar I &owt1$}ett1 personalty 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.
��it1111111111//� :��
PP,\�1ME/v7-F.•S S Notary Public in and for the ate o€Washington,
;kP
n° �OTA9L 9:0 s Residing at >
n a _= ply commission expires: 12 2 a )
•o
'% O C� ��`