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HomeMy WebLinkAboutWAT2020-00031 - WAT Application - 2/4/2020 WAT Zo -. MASON COUNTY COMMUNITY SERVICES RF 1siding.Phrmrrg,Environmental Health Community Hearn '4 FFe � 415 N 6th Street,Bldg 8,Shelton WA 98584, QQ� 69¢ „. Shelton:(360)427-9670 ext 400 •: Belfair.(360)275-4467 ext 400 r• Elma: (360)482-526 _ 4.J 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. ENVIR� 4. Ana roved buildin site plan must accompany this application. N IVi EN 1"A L HEALTH Part 1: Applicant/ Parcel Identification - - Name on Applicant >41 -TRb Ii Date: tt {tut-h ,1)O Mailing Address: Iq , 14gt`'L.h Phone: T?S Parcel Number. - Oat-�{o-qOo?-CC) mote VA Q 26≥t Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit connections) 0 Division of land: XIndividual water source(one connection), #of Parcels? SPL .' Well ❑ Boundary line adjustment 0 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) 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. ❑ 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.masonwa.us. J:\EH Forms\Drinking War Revised 1252018 Individual Water Well WWater well report(attached to application). Depth ft. Well capacity Test(attached to application) 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(attach to application). Water Resource Inventory Area (WRIA)' Development within which WRIA http://Qis.00.mason.wa.us/planning 14 v 15_16_22_ Water use or limitation recorded................................... N/A_____N/A Yes Well Drilled ............................................................. Date _ 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) V tisfactory Determination: s 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 6.6&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). "Reeviewer's Signatures: -Environ. Health: Date CSD Director. Date 2 oft WATER WELL REPORT i P fur ttwrfr o Notice of Intent No, tCOLQG Unique Ecology Well ID Tag No. Bl%4 Type of Work: State of Washington 17 Construction Site Well Name(if more than one well):Q i le(�View Vtleltt Decommission Orittinal installation NOI No., Water Right P rmit/Certificate No. Proposed Urns N Domestfo O tndusteiei a Mtmiaipai Properly Owner Name f3eoffretr'I`arri nan Cl Dewalering El Ltigetioa Cl Teat Well []Draw Cmetrucdoa Types Well 3t set Address Is Ind tttegred: O New well Cl Alteration El Dlfvut, Li Jetted O Cable Tool City 3he110fl County aeon O Deepening O Other C Dug IP Air- O Mud-Rotary Tax Parcel No. 1 0O Dimensions, Diameterofhoring 8 in..to 75 R. Was a variance approved for this well? O Yes ( No Depthofeompleted well 75 A, Construction Details, Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread [P I ❑ s in. +1 71 .250 in. 17 I O ® ( O Location(see instructions on page 2): 111 WWM or O EWM ❑ I ❑ in. _ in. ❑ i 17 ❑ I ❑ jjj ,A-y,of the_ SE 'A;Section,4___ Township 2E1N Range 4W O 1 ❑ in. — in. ❑ I ❑ ❑ 'I C1 I atittxla Exam e:47.1234 47:2504 o I ❑ is in. O I O O I ii ( pl 5) !4 Perforatluast O Yea 61 No 'type of pes'fcrator wed Longitude(Examp r-120.12345) -1231288)ll( No of tw1b ations Size ofuorfaratbns in.by _in. rillsr'111.ogfCopsh nsf NHl orr'Dlesetrt en Procedure Perth red ftarn�_ft.to_-R.below groun d surface Formation:Dgprlb a by color.character,size of materiel and tarnature,and the kind and nature oftbs meterhtl in each Myer genet ated,with at least one bntry ler each change of Screens: P1 Yes O No 611 K-Packer +'+ Depth 89 A, information. the additional sheets if necessary. Manufacturer's Name Alloy Machine Workg Material Type Modal No. $�o_ To Disarmer 54 Slotsise.ote in.Ronn 70 n.to 75 R. Brown sandy loam 0 3 Diameter_„_- Slot size-rn Ram R.to_A. Brown&enc ghivel With cobbles 3 15 Brown maid sandtfrilter peclu Q Yes ®No Size of prrok tutorial_,in. . . 16 33 Rounded mUocord Materiab peal from 1t.ro_.It= prat brown roam. 33 Carfare Segal: O Yes 17 No To what sand,loose 49 Material used in seal t3entonJte Chips depth?fit) R. Multicolored Oraval,brown coarse sand water 49 75 Did any strata contain unusable water? O Yes O No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: H.P.__„_ Pump intake depth:__R. Designed flow rate: gpm Water Levels:Land-surface elevation above mean we level 2!L R. Stickup of top of well casing_+1 I above ground auataee Static water level..jL L below top of well casing Date 11/2112011 Artesian pressure.__par.per square inch Data Artesian water is controlled by (cap,valve,sac.) Well Tests: Was a pumping tess performed? II No O Yes .' by whom? Yield gpm with__ft.drawdown after,—,bra. Yield_gpm with_A.drawdown after___bra. Yield—gpm with A.drawdown after_,,,_hr.. Recovery data(time=zeta when pump Is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Data of pumping teat Boiler test gpm with_R.drawdown after_bra.l Air test 2�(1 gpm with stem set at 0__R.for 1 bra. I}. Data 11/21/2018 Artesian flow__ Van J Temperature of wator_ F Was a chemical analysis made? ❑Yes Irk No Start Date 11121)/2018 Completed Date 1112112018 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 infomtation reported above are true to my best knowledge and belief. 19 Driller O Trainee-Cl PE—Print" me Jo Koepp Drilling Company Arcadia Drilling Inc. signature j Address PO Box 1790 License No.`2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Ucee No. Contractor's Sponsor's Signature Registration No.ARCADD1098KI Date 11121/2018 ECY 050.1-20(Rev 09/18) f/you need this document in an alternate forma?,please call the Water Resources Program al 360-407-6872. Persons with hearing loss can call 71/for Washington Relay Service. Persons with a speech disabli ty can call877.833-6341. 2125461 oT�EMASON CO WA Return to: 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 7 ZafU _ Subdivision Division Lot Range Township Section and having the Tax Parcel Number of q Z 0 —�fl — a d Z D 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: 1"1 Maximum Annual Average Gallons Per Day: 15 o Dated on this _day of 2_�j-1 aZC)a ) Signature of Grantor(s): )r_>41ges :,/ Printed name of Grantor(s): .s tt B /rl S Sr fro ) 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 day of Fir ,20O. o h . personally appeared before me,who is known to the move instrument,and acknowledged that he(she)(they)signed it. Given,under my hand year last above written. (10N0r4;;* h'! k,&LIC Notary Public in and for the Ste Washington, ? Residing at . '•••....?� �• i n expires: 2 �'ASHI My communion o pees: FEB 8 4,-2020 BY. .------------- 1786 SE Mile Hill Drive PortOrchard,WA 98366 _ SPECTRA Laboratories-Kitsap www,s��lab.com , . .....,k., (om)443-7845 RECE/ COLIFORM BACTERIA ANALYSIS FORM r e ��D Deis Sample cc acted me Sempleectod county ra Ocoi ?p?� 1 1 17 120 11 00 O M won 6i 1w, &b* Dy Yw --- ---OPM V A Eder S Type of Water System(track only one box) ❑Group A ❑Group B E Curer Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Bill Neal East Timber Ridge,Shelton Contact Person:Arleta Eisele/Arcadia Drilling yft 1V4#/E., Day Phone.360-426-3395 Cal Phone: 'V T/1 Ernst: arietaearcadiadrilling.com fEveL Phone: Send rear b:(Pdr4fut name,address and zip code or amain) arleta@arcadiadrilling.com Arcadia Drilling,Inc Sample collected by Seth Specific location where sample colected: Special instructions or commenle: Well Head-Wait Well OBKR043 1.0 Routine Distribution Sample 2.Repeat Sample(after unset routine) Chlorinated:Yes❑ No❑ ❑Disinbutlon System Chlorine Residual:Total—Free, Unsatisfactory routine lab number 3.Source Ground Water Rule Sample — —- $ i ——— 1 f Unsatisfactory routine called date: ❑TrIggered Chlorinated:Yes O No❑ ❑Assessment Chlorine Residual:Total___Free 4. t3nmeraeon Source War Sample o E C09 OFeCei-auha.GNA.SYrhacFind Ya� NOD 5.IZI Same Cotected for Infdmac on Only: ctin t and ❑E.col present -- ©Ecoiabsent smmsRequimd 0 Sample tee cld('>30 hours) O TNTC' O BacterialBadenel Density ResuTotal Cclorrn 10 ► 11{N1m1. Fecal Cctm. Jj00mlIll . ., 1f ml r72o2oJ tsbtorwraber Ined SM 9223 B4" 4 y 0 2020 t70Ht.db�Samp�$R�.�- {:hj iiRaOteOr '. nd{ddd*,.plaeNny wraM�M Mw.dRMapaJh*iJok. �