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HomeMy WebLinkAboutWAT2022-00180 - WAT Application - 6/22/2022 WAT 2022- - 001 SO `. MASON COUNTY RECEIVED . COMMUNITY SERVICES __-- q ��y, Building,Planning,Environmental Health,Community Health JUN N 2 "3.rr,,v3H 2 2022 415 N 6'h Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext400 •:• Belfair:(360)275-4467 ext400 •:• Elma:(360)482-52F154 Alder Street FAX(360)427-7787 Application for Determination of WaterAdequacy 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 Ide ificattion Name on Applicant: L _CIAIL.(CUI Date: Lo- a 0.- .0�.2. Mailing Address: Ii432..n 56441.AIE A r4) Phone: I ' -7O6' - Parcel Number: yin- - qI cnav I-1 15" 4L f 1 Z8'4(0 I wcolm.4 (J hQ pj lore- go of Water System go Reason for Application ❑ Public/Community Water System (2 or more Building permit 7)k t 262Z CO' lq1 ri- connectio ❑ Division of land: XIndividual w ter source (one connection), #of Parcels? SPL Well 0 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: Water Facility Inventory (WFI) Number: (write "none" fortwo-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. In 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 1/25/2018 Individual Water Well ❑ Water 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://gis.co.mason.wa.us/planning 14 151 11E= 22= Water use or limitation recorded .. N/A_Ea_Yes �/f 7 1 33 5 to Well Drilled Date I l 14 7 7 I 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) ,tisfactory 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. C Unsatisfactory Determination: Applicant's water supply does not appear adequate to meetthe needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date `1'11ksr)'' CSD Director: Date 2of2 hr�a'. - - -Mi w �;.flu-,m.. RECEIVED JUN 22 2022 WATER WELL REPORT S : DEPAN1MENI or Notice of Intent No. WE45712 615 W. Alder Street ECOLOGY Unique Ecology Well 11)Tag No. BNX172 Type of Wank: — State of Washington . ❑ more Site Well Name(if than one well): Decommission Original installation NOt No Water Right Permit/Certificate No. Proposed Use: 154 Domestic 0'Industrial 0 Municipal Property Owner Name B1.LLC fflairt Buroess • 0 fkwatering 0 Irrigation ❑Test Well Cd Other. Well Street Address 471 SE Ellis Rd Coattrreden Types Methods City Shelton County Maatxt M New well 0 Alteration 0 Driven ❑lotted 0 Cable Tool 0 Deng 0 Other 0 Dag III Air- 0 Mod-Routs Tax Parcel No. 31903-22-90020 • Dimensions: Diameter of boring 6 in,to 118 ft. Was a variance approved for this well? CI Yes B No Depth of completed well 118 ft. Construction Degas: Wall If yes,what was the variance for? Casing Liam Diameter From To Thtickness Steel PVC Welded Thread 154 I 0 6 in. 0 11,5_ 0.25 in C3 1 ❑ i6 1 ❑ Location(see instructions on page 2): C3 WWM or 0 EWM ❑ I 0 _in. in. 01 ❑ ❑ 1 ❑ NW °/.'/•of the N 1f ''A;Section 3 Township 19N Range 3W El 1 0 __in. — _ _in. 0 1 0 0 I 0 4 I ® in. in 0 I ❑ l 3 1 ❑ Latitude(Example:47.12345)47.168891 _ longitude(Example:-120.12345) -123,05175E Perforetims: f.7 Yea fat No Type of perforator used Drlller'a l.tr(rfGonatraetiea or Deeammiasioa Procedure ' Na o£perforations Size mof a ground cur in by in. Formation Describe by color,character,are of material and structure.and the kind and Perforated from fl.to R.Dolma grrwrrl surface astute of the material is each layer penetrated,with at least one entry for ea ti change of Serena: B Yee ❑Na ©K-Packer c Depth 112 R. infonnalioa Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless Slotted Model No. Brown silty clay with gravel 0 3 . Diameter Skint size.018 in.from 113 s.to119 ft.. Brown silty sand and gravel 3 31 Diameter Slot sire re.form a,to®A. 31 34 Brown medium sand Sand/Filter pack:£7 Yea gill No Sim of pack material_in. Brown tlllreiium sand,some gravel loose,wet 34 42 Materials placed from R.la_ft. Brown silty sand,some gravel 42-,...., 78 Surface Seed: Fil Yes 0 No To whet depth? 19 R. sl it lit 78 104. Material reed in seal Bentonite chlos Gray Multicolored gravel medium brown sand. 104 Del any strata contain unusable water? ❑Yes ET NoI e1 water117 Type of watts/ Depth organ* dry 117 118 fine gray sand,tight,Method of sealing strata off Multicolored gravel, Pump: Maafacnuer's Name. Type: H.P.* Poop intake depth: R. Designed Sow rate: gpm . Water Levels: land-eorfaee olcvation above mean sea level 143 ft. . Stickup atop of well casing 1.5 il.above wound statue Static water level 55 I1.below top awed easing Date 11/4121 .Artesian pressure_lbs_per saewre inch Dare ---- h • Artesian water is coorrutkd by (cop,valve.etc.) _— Well Tests: ^.. Was a pumping test performed? St No LI Yes :::::-"? by whom? Yield._sppm with,_-R.dmwdown ski hrs. Yield gpm with .ft..dtewdawe alter,...___less. Yield ,,,_arum with R-drawdawn after his. _ .... Recovery data(time,.zero when ptamp is turned oft-water level measured from well top to water level) Water Level -- Time Warns level Time Water Level Time _ . Date ofpumping test nor �...r- Bailer test apm with„_R.drawdowa alter__.hrs. I • Air lest 17 gran with stem set at 105 ft.for 1 hrs, r Dar 11/4/21 • Artesian flaw. .gpm J Temperature demon 49 •F Was a chemical analysis made? 0 Yes YI No Start Date 11/4/21 Completed Date 11/4/21 . 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 hest knowledge and belie?'. Driller 0 Trainee 0 i'E—Print N' Josh KoePP Drilling Company Arcadia Drilling Inc. Address PO Box 1790 Signature License No.2$74 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor"s License No Contractor's Sponsor"s Signature_ .... .... - Registration No.ARCADDIO9BK1 Date 11/4/21 FCY 050-1-20(Rev 09/I 8) Ifou need this docrrnaenl in an alternate forma please call the Water Resources Program as 360-407-6872. Persons with hearing loss can call711 far Washington Relay Service. Persons with a speech disability eon call 877-833-6341, RECEIVED 1786 SE Mile Hill Drive I U N 2 2 2022 Port Orchard,WA 98366 Sl"IiCT3&A Laboratories-lUtleP www.apectra•lab.com 443-7845 615 W. Alder Street COLIFORM BACTERIA ANALYSIS FORM Dale Sample Collected Time Sample County Collected 11 I 29 J 21 11 00 Slam Mown Iamb err Yew _ Type of Water*hen(chart only one box) ❑Group A ❑Group B DOther Groat A and Guam B Systems-Provide tom Water Fec>Res Inventory(WFI): System Name:Blain Burgess 471 SE Ellis Rd,Shelton Conned Person:Arista EiselelArcadia Drilling Day Phone:380428-3395 Cell Phonic Email: arletatarcadiaddlling.00m Eve.Phone: Send maul*is(Prim ell name,slow end Lp code or toad) arlataltareadiadrilling.corn Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):sear Specllc location where sample collected: Spectra lnabudlons or cnnments: COUNTS please Well Head OSNX172 *mark Satisfactory if passes Type of Sample(dledt only one bee) 1.C)Routes Distribution Sample 2.Repeat Sample(Sher treat.routine) Chlorinated:Yes❑ No❑ 0 Disrbuton System Chlorine Residual Taut._Free Unsatisfactory routine lab number: 3.Source Ground Wan r R:le Sample __ —_ ,-—--- ! gill tlnsatslacsory routes coned date TriggeredChlorinated:Yes 0 No[3 CI Assessment Chlorine Residual Total Free_4.E,iun+waton Source want Saida I Q E cot Crawl-slow com,StOwir Rea*Y..p .0 6.p Semple,Caaadad fox Newman Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Unsatisfactory Total Coltamn Present and i$'8aderadory 0 E present ❑E.cotl absent Replacement Sample Required: Q Sample too nld(>30 hours) ❑TNTC 0 Bacterial Danety Results.Total Coitarm ,.O. al.Jt80m1.E.cot tµpi f 166mi, Facet Calfonn 1100ml. HPC _.1t nl. lab t0 Number Date and Time Received: /r + '5cfl (-)( NO1r 3 0 2021 -\,e6 Method Code: Dale Ntir I3 2021 5M 9223 B DateAnBrred: Dalt 12021 DEC 0 12021 DOH Lab'Sam ttA lab Lk*Ode 226 . ,? L- Ti,n/aaw ii�OPAWL;e1 Y.ioitilkiingtot {r+u.iGntl.iri 11L yp a '=4 ; ' pµ.. ?