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HomeMy WebLinkAboutWAT2022-00036 - WAT Application - 6/8/2022 WAT AT WW - 0603V 4� ,ti,. MASON COUNTY h COMMUNITY SERVICES \ —,.. r .�js .� Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, e �1� Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ow i FAX (360)427-7787 ./D Application for Determination of Water Adequacc,s JUN 08 2022 VV n , Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. '?et 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 Identification Name on Applicant: Jeff Cully- Gritthaus Concepts, LLC. Date: June 8, 2022 Mailing Address: 3818 S 34th St, Tacoma, WA 98409 Phone: 253-592-1782 Parcel Number: 32212-76-00120 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more CI Building permit connections) 0 Division of land: CI Individual water source (one connection), #of Parcels? SPL El Well 0 Boundary line adjustment ❑ Spring/surface water 0 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. ENVIRON'.1ENTAL Part 2: Water Connection Information HEALTH 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 June 8, 2022 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 1 t 0 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/pianninq 14= 15[�]16(-122= Water use or limitation recorded N/A 0 Yes Well Drilled Date 1 11'6-0- 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) 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: Date (e) ('-ir . CSD Director: i 2 of 2 Date i I WATER WELL REPORT i- W i DEPARTMENT OF Notice of Intent No. E45704 ECOLOGY Unique Ecology Well ID Tag No. BAC312 Type of Work: State of Washington ) Construction Site Well Name(if more than one well): 0 Decommission e> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: fE Domestic 0 Industrial 0 Municipal Property Owner Name Ellen Domingo ❑Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 251 NE Sanctuary Lane Construction Type: Method: El New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Tahuya County Mason ❑Deepening 0 Other 0 Dug 0 Air- 0 Mud-Rotary Tax Parcel No 32212-76-00120 Dimensions:Diameter of boring 6 in,to 146 ft Was a variance approved for this well? ❑Yes I]' No Depth of completed well 140 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread l3 I 0 6 in. 0 136 0.25 in. © I 0 O I 0 Location(see instructions on page 2): 0 WWM or❑EWM ❑ I ❑ in. in. ❑ I 0 ❑ I ❑ NW V.-'14 of the NW 1/4;Section 12N Township 22N Range 3W ❑ I ❑ _in. in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. in. ❑ I ❑ DID Latitude(Example:47.12345) Longitude(Example:-120.12345) Perforations: ❑Yes ga No Type of perforator used No.of perforations_ Size of perforations_in.by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to_ft below ground surface Formation:Describe by color,character,size of 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 0 No R K-Packer Depth 134 it information.Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5" Slot size.014 in.from 135 R to 140 ft. Brown fine to medium sandy gravel to 0 Diameter_ Slot size in.from ft.to ft. cobbles,loose,dry 26 Sand/Filter pack ElYes E No Size of pack material in Brown fine sandy gravel,gray silt binder, 26 Materials placed from ft.to it. tight,dry 39 Brown medium sandy gravel,tight,wet 39 69 Surface Seal: M Yes 0 No To what depth? 20 ft- Gray silty clay,stiff,dry 69 75 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes E l No Brown fine to medium sandy gravel,tight,dry 75 106 Type of water? Depth of strata Brown medium sandy gravel,tight,wet 106 119 Method of sealing strata off Brown medium sand,heaving,water 119 135 Brown gravelly medium sand,heaving,water 135 140 Pump:Manufacturer's Name Type. Multicolored sharp gravel,tight,wet 140 146 H.P. Pump intake depth: ft. Designed flow rate: gpm Gray clay,stiff,dry 146 146 Water Levels:Land-surface elevation above mean sea level ft. Stick-up of top of well casing 1 ft above ground surface Static water level 76f ft.below top of well casing Date 1/1 8/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? Ell No ❑Yes =I> by whom? Yield gpm with_ft_drawdown after hrs. Yield gpm with_ft drawdown aPer 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) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test_gpm with_ft.drawdown after_hrs. Air test 15 gpm with stem set at 120 ft.for 1 hrs. ' Date 1/18/22 Artesian flow gpm Temperature of water 51 °F Was a chemical analysis made? ❑Yes El No Start Date 1/17/22 Completed Date 1/18/22 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 iii Driller 0 Trainee❑PE—Print Roger Phythian Drilling Company Arcadia Drilling Inc. Signature i /" Address PO Box 1790 License No.2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/18/22 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-KitsaP www.spectra-lab.com ..Phare upnrence naaerf (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 1 / 20 / 22 CIAm Mason 3 50 Monti Day Yew • m FM Type of Water System(check only one box) 0 Group A 0 Group B DOther Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): 1 ID# System Name: Ellen Domingo 251 NE Sanctuary Ln,Tahuya Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-426-3395 Cell Phone: _ Email: arleta(arcadiadrIlling.com Eve.Phone: Send results to:(Print full name,address and zip code or e-mail) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Special instructions or comments: Well Head #BAC312 Type of Sample(check only one box) 1. Routine Distribution Sample ( 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ 0 Distribution System Chlorine Residual:Total Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample _ —— ___——— IS I I Unsatisfactory routine collect date: ❑Triggered Chlorinated:Yes 0 No❑ ❑Assessment Chlorine Residual:Total Free_ 4. Enumeration Source'Neter Sample ISI I ❑E.coif [(Fecal-Surface,Gl 1,Spring&Monad Yas .0[3 5.0 Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and 'tAatisfactory ❑E.coi present ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform_ . /100m1. Ecoti _ __1100m1. Fecal Coliform I100ml. HPC ..__I1 ml. Lab ID Number Date and Time Received: 7..,1 �' y I}- 2,1e2D U " 6'- JAN1.2022 k Method Code: Dale and lime Incubaled. I SM 9223 B JAN 21 2022 Dale Analyzed: Date Reported: JAN 22 71177 JAN 24 2022 DOH LabSaml_ - Lab Use Only: 225 . � c CON Fare/S]1319 falterY a 04161-Urn creed Ole w6_./to in an dRme5w:amx w7 efQ5250127 frOOMY c4171 t). Ties and celar pate-Mrs are avala:19 2tx-nw oa WaQT7Gat'ac last