HomeMy WebLinkAboutWAT2020--00076 - WAT Application - 6/12/2020 TI
• WAT - OOO'""(
MASON COUNTY
COMMUNITY SERVICES
euaang,panni►o;Em*eoman<aIF1aNRCanrwei*YHedth
415 N 6w 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 I 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 accompàty this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Q C S Co tv Date: 6 TJ 12/ 2 oz o
Mailing Address: L l k 14€.rr ;. CpJ&Phone: 3 (0 ' I.) (
Parcel Number: Q. 2 p jS '" — 960
Lil
Type of Water System Reason for Application i �!
O Public/Community Water System(2 or more ( Building permit ;I
connections) O Division of land:
1 Individual water source(one connection), #of Parcels? SPL
Ir Well O Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain) j.
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.
❑ 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. li
Signature of Water System Manager Date
This farm maybe scanned and available for public view at www.co.mason.wa.I1 1 C1 II I
J:\Ef Forms\Drinking Water Revised 1/25/201 1111 I
JUN 1C 6 2020
Ili i iii.
BY:-------------
Individual Water Well
Water well report(attached to application). Depth 1? 1 ft.
O 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 htto://ais.co.mason.wa.us/olannino 14i%_16_22_
Water use or limitation recorded................................... N/A_____N/A Yes f 4*141
Well Drilled ............................................................... 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
Part 3: Mason County Community Services Evaluation staff use only)
This
water t.*k
Adequacy for áU9 Pei reip. Chapter
38.70A RCW.
[I Unsatisfactory Determi ______ t �
AppNcantswátst supply does ____ ___ needs of its intended use fdi the following
r Health:
1.CSD Director:
w =:2 Of 2
,i, fi 4' __ _ _ *'
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WATER WELL REPORT r _ DEPARTMENT of Notioeofh»eetNo.WE38460
iti ECOLOGY
Unique Ecology Well ID Tag No.B�ff2t8—
Type of Work: State of Washington
construction Site Well Name(if more than one well):
o De ec sm Ch gtna imudWioa NOI No Water Right PermitlCcrtifeate No.WA
Prepared liar a Dc o Iadnstr al n monsival y Owner Name.KTE SCOTT
U Dawatenag [:J migatroo El Test Wen 1.]Other _-.._._.. 81 E MERRIN COVE
Well Street Address
Costnetla Type: Method:
5 New well (3 Alfenthon ❑Driven 1]Jetted ❑Cable Tool City SHaTON County MASON
Op & n other n Dug a Air- 17 M+d-RCt y Tax Parcel No.22015-75-00083
Dom,flfbflngS in,to 121 S Was a variance approved for this well? ❑Yes []No
Depth of completed wen 121 A.
Cons', "ssDetolls: wall If yes,what was the variance for.'
Gmsg Liner Diameter klem To Ttudtaess Steel PVC Welded Thread
N { U e m ,1.5 11a 2..m. IR I U H5 I U Location(see instructions on page 2): [■l W WM or❑EWM
G I C] m. m ❑ I o O I U Nth VrV of the Nw Y.Section 15 Township Range 2
ri I ❑ in. in ❑ 1 ❑ O1O U
L] ► LI m _ in U U Ulatitude(Example:47.12345)Longitude(Example:
{ I
-120.12345)
PerPoraSens (]Yes LINO Yypeofperbralor'mod s)[oR/Co nst>sctias�I>kcemmisdasPncedure I
No.ofper$ratrons__ _ Size ofpbafontws m.by m. Fin Describe by color character,sit maternal and srtacture,and the kind and
Perbomoed tom_8 to-8 below ground snf eee noose of the material m each layer penetrated,with at least one entry for each change of
Seseran LB Yes n No (9 K-Packer c .' Depth 118 n infarmadon. Use aMthmal sheets ifnrcessaty
Mamhtaetwer'sName JOHNSON Material From To
Type STAINLESS STEEL ModelNo TEL
Diameter.L_. in. Slot ewe 14 m from 118 It 14 121 8 BROWN SAND,GRAVEL AND CLAY. 0 22
D arMer_in. Slot sett m'from_S.to_8. SAND AND GRAVEL WEEPS 22 27
Sand/FBter pack:❑Yes N No Size of pack matenal_m BROWN CLAY SAND AND GRAVEL 27 52
Materials pkaced Sam_ft to_8 BROWN SAND AND CLAY 52 75
BROWN CI.AYAM)SAND SOME GRAVEL 75 1
103
&arfihee Beth 19 Yes C]No To what depth?15 t.
BROWN SAND 103
Matenal
d eny st_raa contain a¢mable wares? ❑Yea I9 No BROWN SAND AND GRAVEL WB. 115 121
D
Type of water' — Depth of strata
Method of staling strata off
Paste MmnfrctmeYS Name FRAM0.IN Type:SUB
HP.? Pimp intake depth:114 A Designed Bow rate:t0 spin
Water Levels:Land-meteor elevation above mean see level-It
Stick-up of top of well casing, 1.5 ft.above ground surface
Sparc water level 36.3 ft below top of well casing Date 0810812020
Artesian pressure_the per spse inch Date
Artesian water is controlled by (cap v'al'e.etc)
Wen TOW
Was a panhpmg test perfbnned° L3 No L9 Yes r by whom''T0DC ! II
Yield 14 gbmwdh74-7 ft drawdownaea?hem
Yield,gim with___it drawdown after_,her.
Yield gpm with__8 drawdowa after_his
Recovery data(time—zero when pump is turned off—water level measured from well
top to water level)
Time Water Level Tome Water Level Time waterlevel
Daoeofpampmg test ! — —
Batler test 15 gprn with 75 t drawdown afal_he
Air test gpmwuh stem set at_R low—Ins Date 06/089020
Artesian flow_gpm
Temperature of water_'F Was a chemical analysis made' Li Yes a No Star Date oteswZ020 Completed lyre 08/10/2020
WELL CONSTRUCTION CERTIFICATION: 1 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.
[a Driller❑T inee _ --Print Name Drilling Company TOP DOG DRILLING CO.
Si Address PO BOX 2227
License No.217 City,State,Zip BELFAIR,WA.98528
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.TOPDODD902P8 Date 06/11/2020
I II
ECY 050-I-20(Rev 08/19)Ifyou need tins document to an allvnaate fans,please call the Water Resources Program at 360-407-6872.
Persons with hearing last can call 711 for Washington Relay Service. Persons with a speech disability can cull 877-833-6341.
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SPECTRA Laboratories—Kitsap
26276 Twelve Trees Lane,Suite C,Ponislw,WA 98370
(360)779-5141
COUFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample Colected County
! ' :��oPa, ao
Type of water Systan(check ally one box)
Y
P� ❑Group A ❑Group B . er-
Group ��V°p'A and Group B Systems-Provide from Water Facilities Inventory(WFl):
SystemName3O& Scc
Contact Person: d C r-1
pay c Cal Phone:( )
Eve.Pho . Fax:t ) l
Email Address:
and to: tux n gdms and zip code)
uJA L9
Sample collected by(name):
Spec whero satppb core d: Special instructions or commerrts:
1'pe at Sete(must cheek any eve brat of#1 throupb►5 listed blow)
1.0 Road ee Distribution Sample 2.Repeat Sample(AIP)
(from distribution system after unsat.routine)
Chlorinated:Yes-_-.---No� Unsatisfactory routine lab number
Chlorine Residual:Total___Free
S.Ground Water Role Source Sample —
Unsatisfactory routine collect date:
I gg f
Chlorinated:Yes_—No
❑Triggered(NP) Chlorine Residual:Total Free__
❑Assessment(A/P)
4.❑Sv,act W Gwl Rarr tiataee Wrier SasPM(Enumerati(m) (I s L
J
0 E.coU ❑Fecal Rkwed Yes-No_ �,�•
5. Collected tar latormatioa Only
InvecllDatve__ Constroexon l Repairs PdwN lbsideMe Other
LAB USE ONLY DRINKING WATER RESULTS l.AB)JSE ONLY
❑Uaeathmelory Total Coliform Present and Sstistectory
❑E coil present O E.soli absent
Replaaasmd Sample Rsauested/Flatlled:
❑Sample too old(>30 hours)❑TNTC O
Bacterial Density Results:Total Coliorm /100mi. £cod /100ml.
Fecal Colform_ /100m1. HPC /1 ml.
rhlmcsleed Z� 133 ° Lab Ralenenco aura r
Incubator ' Method
922238
Date/rime Out 111cub0t0r Receipt TN"C(Raw Water)
n fit/
00+1 L*Samplct Refnadu
01 L LQ VA- (v((($�
oOHraeeess.4ta$., doeri5t
Whit-bOH ObrrOua acre-taborabry Green-Wier 9cpaer God-DOH Repiond
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RECEIVED
MAR 12 2020
ENVIRONMENTAL 615 W. Alder Street
HEALTH 2127468 MASON CO WA
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Return to: IIii lii& 'iIE'mrni
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TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I(We),the undersigned grantor(s),hereby place this notice on record that the following described real estate situated
in Mason County,State of Washington;to wit
OR i S
Subdivision Division Lot Range Township Section
and having the Tax Parcel Number of:a c O ( �Jr -- — 1 0 O (A O
�ww rf ��n�.T
is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason
County Code 6,6$. These restrictions ions and conditions are based on location of property and/or Water
Resource Inventory Area or WRU►.
WRIA: !`"f Maximum Annual Average Gallons Per Day: __
Dated on this _day of SV\t+k,r e h ,20 .
Signature of Grantor(s): A c
Printed name of Grantor(s}. c;p �s P 42
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 ratify that on this
!L day of P1 aA2C L ,20) J0�C. h_ N $_C`' ' personally appeared
before me.who is known to be j f the above insttumant,and acknowledged that be(abe)(they)signed it.
Given,under my hand year list above
( /QNOTAIPk1A \ - k�l
t P� a Notary Public in and for the State o as
BCIC gton.
Is Residing at I'l
My commission expires: _..� .._