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HomeMy WebLinkAboutWAT2022-00303 - WAT Application - 8/25/2022 WAT/02Z- 0 MASON COUNTY 0.117117 iCOMMUNITY SERVICES \ _ - Building,Planning Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, FrJ[fin Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482`-� 9 eJtt► J A'bIEI^VITAL FAX(360)427-7787 _ Application for Determination of Water Adequacy CALM Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. � t 2. Complete only the portion of Part 2 applying to the type of water connection utilized. VS.10 3. Submit completed application, with any required attachments for review. 4. An approved building site plan must accompany this application. s,5 ©�u3 ?°Z 14/ 2 Part 1: Applicant/ Parcel Identification • 4/o'er s f Name on Applicant: AA4.1 ah434.--' Date: $(25/2022- tre0t Mailing Address:41/P W4L W S2 /1) Sica-1 Phone: Z1c20 -z{']D - q, - Parcel Number: y(f Z'7 33 000/0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 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. 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J\I:II Forms\Drinking Water Revised 1/25/2018 1 Individual Water Well XWater well report(attached to application). Depth 2 ft. Well capacity Test (attached to application) 2O 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. NSatisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14j 151-1 16n 221-1 Water use or limitation recorded N/A j=Yes p4. Well Drilled Date 4'/9/2z22- Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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. ecommended 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. 17 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: P 1 Date l (O (L3 CSD Director: Date °' Rhonda Thompson From: Gary Blatter <glenterprise@gmail.com> Sent: Friday, January 6, 2023 11:58 AM To: Rhonda Thompson Subject: Fwd: Supplied For Your Review Attachments: Blatter, Gary - BNV891 - 4466 State Route 108, Shelton - Corrected signed well log.pdf Caution: External Email Warning!This email has originated from outside of the Mason County Network. Do not click links or open attachments unless you recognize the sender, are expecting the email, and know the content is safe. If a link sends you to a website where you are asked to validate using your Account and Password, DO NOT DO SO! Instead, report the incident. Rhonda, Please see the below per our discussion. Let me know if you need anything else from me regarding this matter. Have a great day, Gary Blatter 360-470-9952 Forwarded message From: Sue Baldy<sue@arcadiadrilling.com> Date: Fri,Jan 6, 2023 at 8:39 AM Subject: RE: Supplied For Your Review To: Gary Blatter<glenterprise@gmail.com> Hi there Gary, Attached is the corrected well log. I am submitting to DOE. It takes time to show in their system, but consider it done. Sue Baldy sue@arcadiadrilling.com Mailing: Po Box 1790,Shelton, WA 98584 Physical: 21 W Westfield Ct, Shelton, WA 98584 arcadiadrifling.com CORRECTED PARCEL NUMBER WATER WELL REPORT ,:,,,viiag DEPARTMENT OF NoticeoflntentNo WE47168 ECOLOGY Unique Ecology Well ID Tag No. BNV891 Type of Work: 1.1511 State of Washington O Construction Site Well Name(if more than one well): O Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: CI Domestic 0 Industrial 0 Municipal Property Owner Name Gary Blatter 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 4466 State Route 108 Construction Type: Method: E9 New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug al Air- 0 Mud-Rotary. Tax Parcel No. 2r1927,3 J002D 41927-33-00010 Dimensions: Diameter of boring 6 in.,to 88 ft. Was a variance approved for this well? ❑Yes ❑' No Depth of completed well 88 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter Front To Thickness Steel PVC Welded Thread • I ❑ 6 in. 0 87 .025 in. © I 0 O I 0 Location(see instructions on page 2): O WWM or O EWM p 1 0 in. in. ❑ I ❑ ❑ 1 ❑ SW '/,-%of the SW 'Y..;Section 27 Township 19N Range 4W ❑ I ❑ in. _ in. O I ❑ O I ❑ 47.102787 N ❑ 1 0 is _ _ in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) Longitude(Example:-120.12345) -123.180489 W Perforations: 2 Yes 0 No Type of perforator used Air Perforator Driller's Log/Construction or Decommission Procedure No_of perforations 96 Size of perforations 3/8 in.by 1.5 in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from 64 ft.to 84 fl.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes ©No 0 K-Packer Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material Front To Type Model No. Diameter Slot size in.Sons ft.to ft. Brown silt,dry 0 4 Diameter_ Slot size in.from —h.to—fl. Brown fine sand silt,dry 4 16 Brown gravelly fine sandy silt,dry 16 19 Sand/Filter pack:❑Yes O No Size of pack material in. Brown clay-like silt,soft,dry 19 24 Materials placed from ft to ft Gray clay-like silt,soft,dry 24 43 Surface Seal: E Yes 0 No To what depth? 20 ft. Brown fine silty sand,soft,weeps 43 51 Material used in seal Bentonite Chips Brown fine sand,loose,weeps 51 54 Did any strata contain unusable water? 0 Yes 1D No Type of water? Depth of strata Brown fine to medium sandy gravel,sharp. 54 Method of sealing strata off tight,dry 63 Gray clay binding black sharp gravel,tight,dry 63 66 Pump: Manufacturer's Name Type. Brown weathered basalt,moderate,dry 66 87 H.P. Pump intake depth'—ft. Designed flow rate: pm Black basalt,moderate,dry 87 88 Water Levels: Land-surface elevation above mean sea lead 141 ft. Stick-up of top of well casing 1_4 ft.above ground surface Static water level 42 fi.below top of well casing Date 4/5/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? El No 0 Ycs by whom? Yield gpm with fft drawdown after hrs. Yield gpnt with R.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 levd) Time Water Level 'trine Water level Time Water Level Date ofpumping test Bailer test pin with_fr.drawdown after_hrs. Air test 20 pm with stem set at 80 ft.for 1 hrs. - Date 4/5/22 Artesian flow gpm _ Temperature of water °F Was a chemical analysis made? 0 Yes b7 No Start Date 4/4/22 Completed Date 4/5122 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. O Driller 0 Trainee 0 PE—Print Nameff7 Phythian Drilling Company Arcadia Drilling Inc. Signature - 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 4/5/22 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 71I for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Iy t7136 SE Mile Hill Drive RECEIVE ° Port Orchard,WA 98366 —i l` SPECTRA Laboratories-Kttsap wwwspectra-lab.com • ...mtN tlyt/rt(aa/woos (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM NO V 03 2022 Date Sample Collected Time Sample County Collected6 rJ W / ! !.- - 4 ) T ! 22 . 30DMt Mason • Kett Day Yew —�-- Type of Water System(check only one box) ❑GroupA ❑Group E701her ENV;(`�O/� Group A and Group B Systems-Provide from Water FaaTities Inventory(WFI)• r, t.l,�� t ! 1 . ._ AL dl�a System Name:Gary Blatter *164, (, }„`‹. )(A, 4..{ 4 5y, t 1 Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-428-3395 Cell Phone: Emal: arletatilarcadliadriiling.com Eve.Phone: Send results b:(Print rue name,address and zip code or e-mail) • arlefarcadladril ling.com Arcadia Drilling,Inc SAMPLE INFORMATION Stile collected by(dame):Seth Specific location when sample colected: Special instructions or comments: Well Head BNVB91 Type of Sample(check only one box) 1.CI Routine Distribution Sample 2.Repeat Sample(after uhsat.routine) Chlorinated:Yes❑ No❑ ❑Distribution System Chlorine Residual:Total Free Unsatisfactory routine lab number: • 3.Source Ground Water Rule Sample —— —-——.--__---__-•ISI _-- Unsatisfactory routine collect dale: ❑Triggers Chlorinated:Yes ElNo El • Chlorine Residual:Total Free_ ❑Assessment --- I f 4. F3rrneratorr Sane Watr Sample ISI I ❑E.coil ['Fecal-swam o vt aprY:aa feared Yu❑ to❑ 5.Q Sample Welched kr intonation Only: LAB USE ONLY DRINKING WATER RESULTS LAB SE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coll present ❑E.coP absent Replacement Sample Required: ❑Sample too old(>30 tours) ❑TNTC 0 Bacterial Density Results:Total Colfom .._._.. 1100m1. E.coil - __...J100m1. Fecal Cotifforrn_— 100m1. i IiPC_ _._ 11 ml. Method Code: and Time Incubated SM 9223 B AF'e; 0 8 2022 •DateAralyzg ,R 091022 Reported: 2022 DOH LebSmote*A Lab Use Only: 225 . _,_ ._ '6onra.,w,4rita a"nt•nywn.arer.bkr.:..rr i,easuacescosasoWridaomv,atuh Ma ardaset pObRoe. tw,e orraastsede. 2186901 MASON CO WA 08/26/2022 02:55 PM NOTCE BLRTTER #179033 Rec Fee: $204.50 Pages 2 Return To 1110111 III I III III II IIIIII IIF 01100 FII II0FI III IlU UI III iII clikti et Q./Li t( UU }}&.trkso.Jko. 00 OITA rt, ugh q�s� Grantor(s): (1) , (2) Grantee(s): (1) PUBLIC Legal Description (1) N1/2 NW SW SW LOT: 27 OF LLS #518852 2,-1— (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) / / q a 7 - v 3 -Q o Q l_sa TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) I (We), the undersigned grantor(s), hereby place this notice on record that the described real estate situated in Mason County, State of Washington is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These restrictions and conditions are based on location of property and/or Water Resource Inventory Area or WRIA. WRIA: l l Maximum Annual Average Gallons Per Day: ?SC)/ gallons Dated on this day of A-a , 20 22Z Signat of Gra t o (1) OLt''',/ , (2) State of Washington ) County of Mason EIS'►/!RON; 1 ENTAL HEALTH Page 1 of 2 RECEIVED NOV 03 222 615 W. Alder Street s 4 I, the undersigned, a NLotary Public i and for the above named County and State, do hereby certify that on is ISO day of V' " , 20 Z2, (.. is J A t6(9,1 ersonally appeared before me, who is known to be signer ofthe above instrument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day and ye la o ritten. Notary P blic in and for the State of Washington, TIM KRAMER ' residing at `hvrf Si'°►" ' Notary Public My commission expires: S tp 6 Z.OZL State of Washington t Commission# 158978 My Comm. Expires Sep 15, 2024 ONIPWWwwompigpmpqrwift Page 2 of 2