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Home My WebLink AboutWAT2022-00090 - WAT Application - 4/11/2022 WAT 70?,Z - ObC90 � , MASON COUNTY ' �„::-. 1- , , COMMUNITY SERVICES ,,k++ _1 Pn/ilcling,Planning,Environmental 4 tth.Community Health 415 N fill'Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 •:• Belf�FAX(36)275-4467 ext 400 ••• Elma:(360)482-5269 ext 400E Application for Determination of Water Adequacy CEI VEp Instructions 4P 1 i 2022 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. -)15 IA/• f der St, 3. Submit completed application,with any required attachments for review. 4. An approved building site plan must accompany this application. Part 1: Applicant/Parcel Identification Y E N�/!p II HENTAL Name on Applicant: UA 4 i CW t i) Date: / y '` Phone: /// Mailing Address: f?L,,�'>t f J�t�'g1 Ckta�lG��`��Parcel Number: 1223223`IOe?Gt Type of Water System Reason for Application g. permit Building, Public/Community Water System(2 or more 0 0 of land: connections) Division ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name -.,- -` f/ If you have more than one residence connected of water system below if applicable-no \ signature required) to this well, check the Public/Community Water \ System box. ti..-- -.'�" Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: I W d P-4t2-VY "E Water Facility Inventory(WFI)Number: kV/1 (write"none"for two-party) iiY 1 am the manager of this water system.The water system has been approd for a services. There are presently connection(s)in use.This will be the,�nd 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: the limtser system is of the waterasystem orle and lalnng ylimus o osede t by state andthis lo(caereg Iationcti0n(s)without exceeding Ji ( /1 DateSignature of Water System Manager {j This form may be scanned and available for public view at www co•f aso'.wa-u 1:\Elf Forms\Drinking Water Document Ref.DBGBS-UNAWH-XGBXR-QOPCQ Page 1 of 1 Individual Water Well Water well report (attached to application). Depth l `0 v ft. Well capacity Test (attached to application) ' C X 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/planninq 14 15 16_22_ Water use or limitation recorded N/A Yes Well Drilled Date ( /L/6 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) NV 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: Environ. Health: gig`' J Date C> ( This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 t 0WATER WELL REPORT CURRENTNotice of Intent No. 237123 ,,,,„,.. Original&1"copy—Ecology,2"copy—owner,3"copy—driller i:''CI n'I.'(1'r'1' Unique Ecology Well ID Tag No. ALP673 Construction/Decommission ("s"in circle) El Construction Water Right Permit No. EXEMPT WELL 0 Decommission ORIGINAL INSTALLATION Notice Property Owner Name PAUL&LINDA ARCHAMBEAU of Intent Number Well Street Address HARDING HILL ROAD PROPOSED USE: 0 Domestic ❑ Industrial ❑ Municipal City ALLYN County MASON ❑DeWater ❑Irrigation ❑Test Well ❑Other Location NVVI/4-l/4 NW1/4 Sec 32 Twn72N R 1W EWM EDencle TYPE OF WORK: Owner's number of well(if more than one) wwM 0 one m New well 0 Reconditioned Method:❑Dug 0 Bored 0 Driven Lat/Long(s,t,r Lat Deg Lat Min/Sec ❑Deepened El Cable m Rotary ❑Jetted DIMENSIONS: Diameter of well 6 inches,drilled 160 ft. Still REQUIRED) Long Deg Long Min/Sec Depth of completed well 160 ft. CONSTRUCTION DETAILS Tax Parcel No. 122322390020/122322390040 Casing m Welded 6 " Distr.from +2 ft.to 160 ft. Installed: Liner installed " Diam.from fl.to ft. CONSTRUCTION OR DECOMMISSION PROCEDURE ,D'Threaded " Diam.from ft.to ft. Formation: Describe by color,character,size of material and structure,and the kind and Perforations: []Yes 0 No nature of the material in each stratum penetrated,with at least one entry for each change of Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY.) SIZE of perfs in.by in.and no.of oafs from fl,to ft. MATERIAL FROM TO Screens: 0 Yes m No ❑K.-Par Location SILTY SAND,SOME GRAVEL 1 16 Manufacturer's Name BROWN SILTY SAND 16 46 Type Model No. BROWN SILTY SAND,GRAVEL 46 76 Diann. Slot size from ft.to ft. 76 98 Diam. Slot size from ft.to ft. GRAY HARDPAN Gravel/Filter packed:❑Yes m No ❑Size of gravel/sand BROWN SILTY SAND,GRAVEL 98 148 Materials placed from ft.to fl GRAVEL,SOME SAND,WATER 148 160 Surface Seal:0 Yes ❑No To what depth?20 ft. Material used in seal BENTONITE CHIPS Did any strata contain unusable water? 0 Yes m No Type of water? Depth of strata Method of sealing strata off PUMP: Manufacturer's Name Type: H.P. WATER LEVELS: Land-surface elevation above mean sea level ft. Static level 116 ft.below top of well Date 3/28/06 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?0 Yes m 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(lime taken as zero when pump turned offI(water level measured front well top to water level) Time Water Level Time Water Level Time Water Level Date of test Bailer test gal./min.with ft.drawdown after hrs. Airiest 20 gal./min.with stem set at 150 ft.for 1 hrs. Artesian flow g.p.m. Date Temperature of water Was a chemical analysis made? ❑Yes m No Start Date 3/27/06 Completed Date 3/28/06 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. ❑Driller 0 Engineer❑Trainee Name(P _N SON Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature Address PO BOX 1790 Driller or trainee License No. 1886 City,State,Zip SHELTON WA 98584 If TRAINEE, Contractor's ARCADDI098K1 3/29106 Driller's Licensed No. Registration No. Date P �eye' Driller's Signature ',j jy'Jy+y� Mason \�(� �i" " l U-1 (IZev"sp - Count limb m Ecology is an Equal Opportunity Employer. Printed from Mason County DMS RBI Port Orchard, WA 9e366 1 . 1` g a Date Sample 07.7s.w. : : ;saver t I'14I a2. sag p4 YIlir , 1L: o.e• irrictwo Typo of Water System( artty one bat) ~ Q Group A ❑Gimp R r Group A end lGroup a Systems-Pitaride tom Wi erFatileslareeket System Now Vidvrett-c.; 1,4-% k&022,A. Called Peal n: Dort Rena Cd Mane I sew: Evit RkellfoltM-670/ Send m SYt:(PrtkMertkr.adUlas*coact wit/boss for'karat opyor VCIA-YLIc (40,4, i? Sample colested by(Roney sci Specibc bailee where sample co$edet Specdat!intrados arcommsna Jdl 'Q I.1:1 Routine Dlabibution earn*(AlP) 2. Reple t+1P1 Chlorinated:Yee p No p aka deehltuloe woo per wait nndtret Uneoblissloty iodine' C hlodmi Residue Total Frio_ _ tab water 3 Ground Weer Rule Souroa Sample f I i UnsethsfectotyrorRneecoIeaoaim Chlorinated: ®Tn96ered WM Chlotine Residual:Totes Free__ ❑Assessment(AP) 4,Sudo*Or OWI Rift loormaYiator ) I I I_ 9 E col Ohm mime 6 c .. . to.MOIretkaO* 0 • • Total Catibrm PmeanlaW • CI r«coterdent "❑Ecarobeiet Bacterial Danity Racer Total Califon mpnit0Ornt. Rad Cdfarrit ... du/100mi. Repbeement Satoh)smutted: Q TAi'1c CI Seripfataocid 0 Smola Volume 0 Container D E ONO Amp C: Method Code `T•CatiN118147220 qattlef 011 . r 'raknootr.wrt ...irarrtYpaonaaapArw JUN .7 r�mareaart�ra�n�oaaar.smrar�arb aena+aa,ate iwai aiaw�oraaau r� +no4Mr+.mlyM.aaMi�adMiyr 'rd4S.d Otad-aaspNa flown.pw+p ArrrwMraYwrlrNuiwrrad6....0 lb iiff�� 99! 4/ :raWNly�aY11rry,7eu�rMOaotbgatl�wtlngt ....�. :Ef!i ,�il7yi��4Mti� wrl6�tpOal�lgMmiM: