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HomeMy WebLinkAboutWAT2022-00307 - WAT Application - 11/8/2022 y`s,.c •Ply WAT 2 (xj 22 - -y1- \� I .;r MASON COUNTY • , COMMUNITY SERVICES �-�--� ��h,, ��tir Building,Planning,Environmental Health,Community Health �!>1•I I L I___ 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400 FAX(360)427-7787 Application for Determination of Water Adequacy 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 Identification Name on Applicant: Crystal Mannila Date: I I- • Z.L. Mailing Address: PO BOX 1221, Allyn WA 98524 Phone: 360-620-1865 Parcel Number: 22114-14-50040 Type of Water System Reason for Application El Public/Community Water System (2 or more 0 Building permit ICI 2.0ZL UIL.3� connections) 0 Division of land: 0 Individual water source (one connection), #of Parcels? SPL 0 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. 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 4 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 • i Individual Water Well ‘4 Water well report(attached to application). Depth Z�2 ft. AWell capacity Test(attached to application) Z0 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). ,ii Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14t15Q 1bl_J 2217 Water use or limitation recorded N/A c Yes Well Drilled Date i ,-(. I Z Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection 4 ❑ 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 1 • • 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. I 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: �YV 1 Date Z r/7i 1 Z� 2°'2 CSD Director: Date WATER WELL REPORT „vas DEPARTMENT OF Notice of Intent No. WE50761 ECOLOGY Unique Ecology Well ID Tag No. BNX287 Type of Work: W State of Washington O Constnxtion Site Well Name(if more than one well): ❑ Decommission �__:.: Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: al Domestic U Industrial U Municipal Property Owner Name Crystal Mannila 0 Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 120 E Wild Grape Way Construction Type: Method: E New well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool City Grapeview County Mason 0 Deepening 0 Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 221 1 4-1 4-50040 Dimensions: Diameter of boring 6 in.,to 232 ft. Was a variance approved for this well? ❑Yes El No Depth of completed well 232 ft. Construction Details: Wall If yes,what was the variance for'? Casing Liner Diameter Front To Thickness Steel PVC Welded Thread p I 0 6 in. 0 232 .025 in. 0 I 0 J I ❑ Location(see instructions on page 2): ©WWM or 0 EWM O I 0 in. _ _ tat. ❑ I 0 0 1 0 SE ''/.-%of the NE 'V.;Section 14 Township 21 N Range 2W ❑ 1 ❑ in. in. ❑ I ❑ ❑ I 0 ❑ I ❑ in _ in ❑ I 0 ❑ 1 ❑ Latitude(Example:47.12345) 47.309656 Longitude(Example:-120.12345) -122.888898 Perforations: 0 Yes O No Type of perforator used No.of perforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Formation:Describe by color,character,size of material and stnmcture,and the kind and Perforated from R.to lt.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes 0 No 0 K-Packer r-=> Depth lt. information. Use additional sheets if necessary. Manufacturer's Name __--- Material From To Type Model No. Diameter Slot size _in from ft.to it. Brown silty sand and gravel 0 16 Diameter Slot size in.from f.to a. Brown sand and gravel with clay binder 16 35 Brown medium sand,multicolored gravel,wet 35 51 Sand/Filter pack:0 Yes CI No Size of pack material in. Materials placed(ions It.to I. Gray medium sand and gravel,wet 51 67 Gray silt 67 74 Surface Seal: 110 Yes ❑No To what depth? 19 ft. Gray silty clay 74 95 Material used in seal Bentonite Chips Did any strata contain unusable water'? CIYes ElNo Gray fine sand,silt,water 95 99 4' Typo of water? Depth of strata Gray silty clay 99 104 Method of sealing strata off Gray sticky clay 104 112 Brown sticky clay 112 118 Pump: Manufacturer's Name Type: Gray sticky clay 118 126 t l.P. Pump intake depth: ft. Designed flow rate: gpm Gray sticky clay with lenses of sand and gravel 126 143 Water Levels: Land-surface elevation above mean sea level 200 f. Brown sticky clay and peat 143 155 Stick-up of top of well casing 1 ft.above ground surface Brown silty sand and gravel 155 158 Static water level 164 ft.below top of well casing Date 1/24/23 Artesian pressure lbs.per square inch Date Gray fine sand,silt,water 158 161 Artesian water is controlled by (cap,valve,etc.) Brown fine silty sand,some gravel,tight 161 199 Multicolored gravel,brown medium sand,water 199 203 wen't'ests: Brown fine to medium sand,tight 203 218 Was a pumping test performed? i No ❑Ycs t-� by whom? Yield gpm with ft.drawdown after firs. Multicolored gravel,brown medium to coarse 218 Yield gpm with ft.drawdown after hrs. sand,loose,water 232 Yield _gpm with ft.drawdown alter hrs. Gray silty sand and gravel,tight,dry 232 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.1 Air test 20 gpm with stem set at 220 ft.for 1 hrs j- Date 1/24/23 Artesian flow gpm Temperature of water 50 "F Was a chemical analysis made? ❑Yes O No Start Date 1/23/23 Completed Date 1/24/23 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 E Driller O'trainee 0 PE-Print Nal Josh Koepp Drilling Company Arcadia Drilling Inc. Signature 77j,..' Address PO Box elto790 License No. 2874 ' City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/24/23 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. T • 1786 SE Mile Hill Drive Port Orchard,WA 98366 - 11� SPECTRA Laboratories-Ki.tsap www.spectra-lab.com Who,,,,r,rb.rrc„er,r, (360)443-7845 • COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County --_^ Collected 1 / 24 I 23 3 55 Ei Mason -"-"' mP1A Moat, iMoat, UJy 1'oN Type of Water System(check only one box) ❑Group A ❑Group B Dottier Group A and Group B Systems-Provide horn Water Facilities Inventory(WFI): ID# — — System Name: Crystal Mannila Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-426-3395 Cell Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send resuths to:(Print hall name,address and zip rode or e-mat) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name): Max Specific lccation where sample collected: Special instructions or comments: 120 E Wild Grape Way,Shelton Type of Sample(check only one box) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Clh:lonr,aled.Yes❑ No❑ ❑Distribution System Chlorine Residual:Total Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample — I S I I I Unsatisfactory routine co)ect date: J I I ❑Triggered Chlorinated:Yes❑ No 0 ❑Assessment Chlorine Residual:Total_ Free 4. Enumeration Some Water Sample I S l E.coil ['Fecal-Surface.Gvn,sprngs:Ftlrutl Yes❑ No❑ 5.1]Sample Collected for Inforrnaton Only: LAB USE ONLY DRINKING WATER RESULTS LAB E ONLY ❑Unsatisfactory Total Coliform Present and atisfactory ❑E.coli present ❑E.coli absent • Replacement Sample Required: ['Sample too old(>30 hours) ❑TNTC ❑ - Bacterial Density Results:Total Coliform______. FI00ml. E.coi__ Fecal Coliform _.--__1100m1. HPC.__.. ___ /1 ml. Leb ID Number Date and Time Received: R P- 1`'>(���1� "o JAN 2 5.21123 -t33 Method Code: Date and lime Incubated_ /` t SM 9223 B Da:e Analyzed: ate Reported: JAN 2 5 2023 JAN 2 6 2323 DOH Lab-Sampleg Lab Use Orly. .(Ol U 330 a OOH Fcen vs3f.3r9 toeu,,0416J•If uu needrf;pNuncuin o slrrratro r Err4 cell e0C.i2iour rrnf. i c!111J Th:rsrd duo pdd:a6ome aysiw.,a'A...d-A.gahYnkiNgsttr. _ -.. aw 2190421 MASON CO WA 11/08/2022 02:02 PM NOTCE CRYSTAL MANILLA #181655 Rec Fee: $204.50 Pages: 2 Return To I IIII II II II III I 1 IIIIIII I0 II IIII V I IIIV 11111111111 I I IIIII IIIII IIII IIII .9 HA,hn tte ' Yabx �221 A\Aup, u1Y - 9 (652- Grantor(s): (1) C1.� Rt�xr114�L , (2) Grantee( s):s): (1) PUBLIC m - 1,4-2A - Z Legal Description (1) Li } "-I O r LL,`.; Q 7- OP) - 10 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) I ` - S 0 0 '--t 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: Maximum Annual Average Gallons Per Day: 1`7(.\ gallons Dated on this (b day of tJ0(O'Y11,Gv , 20 V-. Signat e oflirantor(s): (1) , (2) State of Washington ) County of Mason ) 4 4 Page 1 of 2 I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this er day of }JOVPrwty3P.Q_ , 20 22 Ccys-ram. YMaxittA;14 personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day a d year las ... - ',en. Notary Public ' State of Washington Notary Public in and fo h- .tate of Washington, ARIANE M PAYSSE �/y� / A s�,n MY COMMISSION EXPIRES residing at /'/G[w r` eo Limmipimsemaiiit2m0Ximinio. My commission expires: 1 22/ Zo25 Page 2 of 2