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HomeMy WebLinkAboutWAT2023-00012 - WAT Application - 1/12/2023 I WAT aQ R,b, coo I a MASON COUNTY RpN Mt- .F COMMUNITY SERVICES N <NV �\A Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, { �� Shelton:(360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 Elma:(360\4 5269 ex 419k1M FAX(360)427-7787 1 ,b 1 L�U�� ' Application for Determination of Water Adequacy A‘dec Strut 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: /4— Date: Mailing Address: / yv/ /,4s-7c cs ar/.<If/ Phone: 06c) 714 77,6 Parcel Number: ?/ 9/-3/ ai222-0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more a_ Building permit OL.92M3-#00041D connections) 0 Division of land: f ( Individual water source (one connection), #of Parcels? SPL /` 6Well 0 Boundary line adjustment Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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 F ovide water to this (these) connection(s)without exceeding the limits of the water system or any limbs set by state and local regulation. Signature of Water System Manager Date -d • \ills This form may be scanned ana available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 • 1r\ Individual Water Well Water well report(attached to application). Depth \'Ce) 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. V, Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14�15n 16l 22n Water use or limitation recorded N/A 0 Yes Mt Well Drilled Date ( c7?i� 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: is 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 1 Unsatisfactory Determination: Applicant's water supply does not appear adequate to meekhe needs of its intended use for the following reason(s). Reviewer's Signatk 's= / Environ. Health: �VV1 — Date V/1 - 2°tz CSD Director: date tiv - ENVIRONMENTAL RECEI D t - Io.,?03-nocyn • HEALTH JAN 1 9 2021 WATER WELL REPORT OE&TY tree of Intent No. WE50780 Unique Ecology Well ID Tag No. BNX284 Type of Work: State of Washington ID Construction Site Well Name(if more than one well): ❑ Decommission r=:::. Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Alec Manke 0 Dewatering ❑Irrigation 0 Test Well 0 Other Well Street Address Lynch Rd Construction Type: Method: IE New well ❑Alteration ❑Driven ❑Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other ❑Dug Ill Air- ❑Mud-Rotary Tax Parcel No. 31901-31-00220 Dimensions: Diameter of boring 6 in.,to 183 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 183 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread I ❑ 8 in. 0 176 .025 in. © I ❑ 0 I 0 Location(see instructions on page 2): 18 WWM or❑EWM ❑ I ❑ in. in. ❑ I ❑ DID NE ''/.-1/4 of the SW A;Section 1 Township 19N Range 3W DID in. _ _ in. ❑ I ❑ DID DID in. _ _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.162837 Longitude(Example.-120.12345) -123.006510 Perforations: ❑Yes ❑O No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure 1 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: lid Yes ❑No O K-Packer ' Depth 174 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 in.from 175 ft.to 180 ft_ Brown medium sand and gravel 0 9 Diameter 5" Slot size.000 in.from 180 ft.to 183 ft. Gray medium sand and gravel 9 23 Brown medium sand and gravel 23 31 SaodfFilter pack:0 Yes ❑a No Size of pack material in. Materials placed from ft.to ft. Gray medium sand and gravel 31 35 Brown medium sand and gravel 35 53 Surface Seal: IC Yes 0 No To what depth? 20 ft Brown silty sand,wet 53 64 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes 0 No Brown silt 64 72 Type of water? Depth of strata Gray silt 72 79 Method of scaling strata off Gray silty clay 79 95 Black sharp gravel,fine gray sand,silt,tight 95 134 Pump: Manufacturer's Name Type: Black gravel,fine to medium black sand,loose 134 156 fi.P. Pump intake depth:_ft. Designed flow rate: gpm Multicolored gravel,brown fine to medium 156 Water Levels: Land-surface elevation above mean sea level 180 ft. sand,wet 173 Stick-up of top of well casing 1 ft.above ground surface Multicolored gravel,black,fine to medium sand, 173 Static water level 142 ft.below top of well casing Date 1/5/23 182 Artesian pressure lbs.per square inch Date loose,water Artesian water is controlled by (cap,valve,etc.) Fine to medium black gravel 182 183 Well Tests: Was a pumping test performed? O No ❑Yes by whom? Yield gpm with_ft.drawdown after hrs. 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 front well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test 1 Bailer test gpm with_ft.drawdown after_hrs. Air test 20 gpm with stem set at 170 ft.for 1 hrs. — Date 1/5/23 Artesian flow gpm _ Temperature of water 50 °F Was a chemical analysis made? ❑Yes O No Start Date 1/4/23 Completed Date 1/5/23 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. 0 Driller❑Trainee O PE—Print Name Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License o. Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Date 1/5/23 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 7l 1 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. iL0g0o23-coO5/6 1786 SE Mile Hill Drive Port Orchard,WA 98366 RECEIVED �t3P&CTRA Laboratories-KitsaP www.spectra-lab.com _mum monism*Neuter: (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM '^,N 1 9 2023 Date Sample Collected Time Sample County Collect 1 1 10 / 23ed ou+ Mason 615 W. Alder Street ran Day Year •. 50 DFM Type of Water System(check only one box) ❑Group A ❑Group B �Qther Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# ENVIRONMENTAL. System Name:Alec Menke HEALTH Contact Person:Arleta EiseielArcadta Drilling Day Phone: 360-426-3395 Cell Phone: Email: arleta@arcadladrilling.com Eve.Phone: Send results to:(Print full name,address and zip code or email) arleta@arcadiaddlling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Max Specific location where sample collected: Special Instructions or comments: #BNX284 Lynch Rd,Shelton 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 S I I I Unsatisfactory routine collect date: ❑Triggered Chlorinated:Yes El No El Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample IS I I I ❑E.coil ❑Fecal-&rho,GN1,Springs:Fiat ed YesEI No Ei 5.El Sample Collected for Information Only. LAB USE ONLY DRINKING WATER RESULTS LAB US ONLY ❑Unsatisfactory Total Colifarm Present and tisfactory ❑E.coti present ❑E.cofi absent Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC O Bacterial Density Results:Total Colitomi — 1100m1. E.coii1100mI. FecalColifoim__ —_-1100m1. HPC I1 ml. lab 10 Number �aAN 1 lie froir. Method Code:SM 9223 B J I LU(3 v �ntrip a lye ted. Date Analyzed: Date Reported: JAN 112023 -_ JAN 1 21llis DOH Lab-Sam led r Lab Use Only: 225 . �,Qbl-- OCH Form e331419(ee4dM0eie)•Yyoe ewd 9fe pbtntn in n slur sew ram*<eo e)7.525.o+n(Toorr1Y ed 711), To.me ether p tMMen as e4.9ei4 ww.doh... foirit4^'da. 4, . e)LQ RC33 -dooL-ID 21923'85 MASON CO WA 01/03/2023 02:47 PM NOTCE MPNKE 11183160 Rec Fee: $204.50 Pages 2 Return To i� �������������������i������������������������ ��������i��l ii /C4-9 i- -�:rea/A- JAN 1 2 2023 615 W. Alder Street ENVIRONMENTAL HEALTH Grantor(s): (1) 14/r.L , (2) Grantee(s): (1) PUBLIC Legal Description (1) (01/7-Le,/ ? //,./d) S <'- /5_ 3 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1)3 / G? / / - C36? 2 2- c) 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 `T i Maximum Annual Average Gallons Per Day: Cr 6o gallons Dated on this day of -3i & i,—/ , 20 01- ;► . Signature of Grantor(s): (1) , (2) State of Washington County of Mason ) Page 1 of 2 4 0 4 I, the undersigned, a Notary Public in and for the above named County and State, do hereby c rtify that on this "3(Nay of y iAt I( , 20 23 , `tc— l'\(\! 0,\ perso Ily 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 and year last above written. JENNIFER WALTERS 1 a ubiic in and for the State of Washington, NOTARY PUBLIC#161707 STATE OF WASHINGTON residing at S 4.oj.A-pv\ W" COMMISSION EXPIRES SEPTEMBER 29,2024 Mycommission expires: `'l ... P Page 2 of 2