Loading...
HomeMy WebLinkAboutWAT2021-00481 - WAT Application - 6/9/2022 ;-c:p WAI2oz1 - ci4 l , MASON COUNTY �, i.f '1. ' COMMUNITY SERVICES Y_ i,3. HLw��0^/' Building,Planning,Environmental Health,Community Health O� � 415 N 6th Street, Bldg 8, Shelton WA 98584, 'r ��'Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 •:• Elma: (360) /4e,•9 7R ( ,,,< \ V � % `'P• FAX (360)427-7787 Application for Determination of Water AdequacyDE. 1 7 2021 Instructions 3 W. Alde Street 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. RE,)''`F!\ C 4. An approved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification J U N 0 9 2022 Name on Applicant: Day)ILL tlp,l Date: IA - l %55IW. Alder Street Mailing Address: . F Ay1J " t I YL,.. Phone: c:a53 -310- 5-153 Parcel Number: 113 -. 610033 Ir6-Rev I at) LOA c18541v Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit ( ai 1 —6117 Z onnections) )iki ❑ Division of land: Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment El Spring/surface water 0 Other(explain) ❑ Other(explain) El 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. 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 1/25/2018 Individual Water Well ,, Water well report (attached to application). Depth kCC1 ft. gWell capacity Test (attached to application) 7J) 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 14V 151_1 16=22= Water use or limitation recorded N/A �Yes)( I Well Drilled Date `c� �(7(Z t 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) , 1 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 6.68.040-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: II"1Izti Environ. Health: -/\-Y\e)1\11\ir 1(\f1 Date 2°' CSD Director: Date • WATER WELL REPORT = ''_t�' fR11:N1 of Notice of intent No. WE46839 rri %f`:� ECOLOGY Unique Ecology Well ID Tag No. BNX225 "type of Fork: State of Washington J Construction Site Well Name(if more than one well): ❑ Decommission =-J Original installation NOl No. Water Right Permit/Certificate No. Proposed Ilse: L■l Domestic 0 Industrial 0 Municipal Property Owner Name Daniel Feist 0 Dewateting 0 litigation 0 Test Well ❑Other Well Street Address 31 E Green Way Construction Type: Method: E New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Grapeview County Mason ❑Deepening 0 Other 0 Dug G Air- 0 Mud-Rotary Tax Parcel No. 22113-31-90033 Dimensions: Diameter of boring 6 in..to 161 ft Was as a variance approved for this well? 0 Yes En'No Depth of completed well 159 It. - - ---- --- - if yes,what was the variance for? Construction Details: Fall Casing Liner Diameter From To Thickness Steel PVC Welded Thread I ❑ 6 in. 0 156 .025 in. I ❑ I 0 Location(see instructions on page 2): Cl_.WWM or❑EWM 0 I 0 in. — in ` I =1 ❑ I ❑ SE 1/4-1 of the SW '/a;Section 13 Township 21N Range 2W ❑ I ❑ in. in. ❑ I ❑ ❑ 1 iJ a I a in. in ❑ i ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.304452 ---- Longitude(Example:-120.12345) -122.880747 peeroratimeu 0 Yes CI No Type of perforator used -- %o.ofperiinations Size ofperfomtiims M.by in, Driller's Log/Construction or Decommission Procedure Perforated from R.to ft below ground surface Formation:Describe by color,character,size nl'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: O Yes ❑No ©K.-Packer '' Depth 153 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works ._._._. Material From to Type Stainless Slotted Model No. Diameter 5" Slot size.012 in.from 154 ft,to 159 ft. Brown soupy clay 0 4 Diameter Slot size in.from ft.to fi. Gray silty clay with gravel 4 11 Gray silty sand and gravel 11 34 Sand/Filter pack:D Yes O No Size of pack material in. Black medium gravel,sand,loose,wet 34 39 Materials placed lion ft.to ft. - -- Gray silty clay 39 41 Surface Seal: E Yes ❑No To what depth? 19 ft. Black medium gravel,medium to coarse sand 41 Material used in seal Bentonite Chips •-•---I Did any strata contain unusable water? 0 Yes E i No loose,wet — 72_,_---- Type of water? Depth of strata Gray clay hard 72 94 Method of sealing strata oft' Dark brown peat 94 100 - Brown silty sand and gravel,tight,wet 100 119 Pump: Manufacturer's Name 1 i e.__________ Gray medium to coarse sand,some gravel 119 134 II.P. Pump intake depth: ft. Designed flow rite: gpm - -- Black gravel,medium to coarse sand, 134 Water Levels: Land-surface elevation above mean sea level 160-ft. loose,water 159 — Stick-up of top of well casing 1 ft.above ground surface Black siltysand and gravel 159 161 Slane water level 105 ft.below top of well casing Dale 5/17/22 - Artesian pressure.- lbs.per square inch Date._..-._Artesian water water is controlled by (cap,valve,etc•) Well Tests: - Was a pumping test performed:' l No CI Yes by whom?-_- _-- - - Yield gpm with- ft.drawdown after firs. -1 Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after____hrs. Recovery data(time zero when pump is turned off-water level measured from well -_ top to water level) Tine Water Level Time Water level Time Water Level --- --I • I Date of pumping test______ Bailer test gpm with ft.drasvdowp after___hrs. l Air test 20 gpm with stem set at 130 ft.for 1 hrs. ?- Date 5/17/22___ ____ Artesian flow gpm _ I 1 Temperature of water, F Was a chemical analysis tondo? 0 yt__Et vo _ I I Start Date 5117/22 Completed Date 5/17/22 1 L.__ WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept respon ibility 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:beq knowledge and belief Ll Driller 0 Trainee D PE-Print Name Josh Koepp D, lltttc:Company Arcadia Drilling Inc. Stgnatutc -;_/ ...i• Address PO Box 1790 License No. 2874 c--• 4 ,.--,...._ C'ity,State,Zip Shelton,WA 98584 iF TRAINEE:Sponsor's License No. - Contractor's Sponsor's Signature -- -Le i tratio 1 No.ARCADDI098K 1 Date 5/17/22 -- F.CY 050-120(Rev 09!1 I) If you need this document:n a+atternat».f rural,please call the Welter Resources Program at 360-407-6872. Persons with heariatg loss can aril 711 for 4 astai ngto t Relay'i'en,ice. Persons-with a speech disability can call 877-833-634/. 1786 SE Mile Hill Drive Port Orchard,WA 98366 1 SPECTRA Laboratories-Kitsap www,spectra-.Iab.com wu r ax„a.i«.,,,,,,, (360)443-7f345 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 5 / 23 / 22 Collected 3 , 55 raft, Type Mmb NY yew - Type of Water System(check only one box) —� 0 Group A ©Group 8 2]Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Daniel Feist 31 E Green Way,Grapeview Contact Person:Arleta Elseie/Arcadia Drilling Day Phone:36042S-3395 Cell Phone: Email: arleta@arcadiadriiiing.com Eve.Phone: Send results to:(Print full name,address and zip code or email) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Spedal instructions or comments: Well Head #BNX225 Type of Sample(check only one box) 1.CI Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes❑ No 0 0 Distribution System Chlorine Residual:Total Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample IS I 1 I Unsatisfactory routine collect date: ©Triggered Chlorinated:Yes El No❑ ©Assessment Chlorine Residual:Total__Free __ 4. Enumerator.Source Water Sample ISi [�E cell OFecal-see,crre,springs:Filmed Yes 0 No❑ —w 5.[Q Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and (g datisfactory • • 0 E.coli present 0 Ecoliabsent• ?\\ Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coition /100m1. E cell )100m1. Fecal Conform..___._ 11 Ooml. RPC_.___..._ 11 ml. Lab ID Number Date and Time Re'<;sivad 110\LA - MAY 2 4 Nil ni,5 Method Code* Data end Time Incubated: SM 9223 B fui Date Analyzed: 5/25/22Date, ported: 5/25/22 mil l Lab-Sans:10 Lab Use Only. 225 - fl ) DOH Fcm#33-1319('Ha-4s+c u'en-1!ya;, tit pieettunit:M*nmffw Iemnl,urof 009.515:e12717DeillY asf!711). fire+d:(he pAr'c :mere symede e:waW.6e1:41ega99i:*Vmasr.