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HomeMy WebLinkAboutWAT2022-00345 - WAT Application - 12/15/2022 • WATgo2,a- OO 9 1A , MASON COUNTY N\j‘P,OW\ �\ flFe COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 Elma: (360)482-5RExt t e" D FAX(360)427-7787 Application for Determination of Water Adequacy DEC 1 5 2023 Instructions 615 W. Alder Street 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: Lisa Mellinger Date: 12/15/2022 Mailing Address: 7801 25th AVE E Phone: 917-843-8008 Parcel Number: 220207590092 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more El Building permit connections) ❑ Division of land: El Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment ❑ Spring/surface water 0 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) 0 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. 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: 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 12/15/2022 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Rcviscd 1 25'201 R Individual Water Well { Water well report (attached to application). Depth 2-AU ft. `{ j Well capacity Test (attached to application) ,0� 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://qis.co.mason.wa.us/planninq 1 "4 15E2 161-1 22(—I Water use or limitation recorded N/A 0 Yes Well Drilled Date 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: '0\1- o 1 l Date (Z (-CS ,°r2 CSD Director: Date • . V1RONMENTA' L RD 2,2,....d 15 -7 (4, EN HEALTH WATER WELL REPORT t....11MilDEPARTMENT OF Notice of Intent No. WE50334 ECOLOGY Unique Ecology Well ID Tag No. BNV828 Type of Work: W State of Washington ^ i-i�r O Construction Site Well Name(if more than one well): {- ^ Y I n 0 Decommission Original installation NOI No. 1 v r;iWater Right Permit/Certificate No. (��7 3 Proposed Use: al Domestic 0 Industrial 0 Municipal Property Owner Name Lisa Mellinger IAN 1 0 20 7 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 251 E Big Skookum Rd Construction Type: Method: 0 New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mai 5 W Alder Strfot 0 Deepening ❑Other 0 Dug t7 Air- 0 Mud-Rotary Tax Parcel No. 22020-75-90092 Dimensions: Diameter of boring 6 in.,to 218 _R. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 216 ft. Construction Details: WTI If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I 0 6 in. 0 216 .025 in. © I 0 0 I 0 Location(sec instructions on page 2): El WWM or 0 EWM O I 0 in. in. ❑ I ❑ ❑ I ❑ NW y-'.of the SE '/;Section 20 Township 20N Range 2W ❑ I ❑ _in. in. ❑ I ❑ ❑ I ❑ O I 0 in. in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.207079 N Longitude(Example:-120.12345) -122.954466 w 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 Perforated from ft.to R.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: Cl Yes CI No K-Pack er `Zr Depth 210 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Type Wire Wrapped Model No. Material From To Diameter 5 Slot size.014 N.from 211 ft.to 216 ft. Brown gravelly silty fine sand,dry 0 4 Diameter Slot size in.from ft.to ft. Brown fine sandy gravel,silt bound,tight,dry 4 31 Brown gravelly fine sand,gray silt binding,dry 31 37 Sand/Filter pack:0 Yes a❑No Size of pack material in. Black boulder 37 39 Materials placed from ft.to R. Surface seat: O Yes ❑No To what depth? 20 R. Brown fine sandy sharp gravel,silt binding, 39 Material used in seal Bentonite Chips tight,dry 52 Did any strata contain unusable water? ❑Yes O No Gray sharp gravel,tight,dry 52 54 Type of water? Depth of strata Brown fine sandy gravel,moist 54 62 Method of sealing strata off Black claylike silt,gravelly,tight,dry 62 75 Brown pea gravelly medium sand,wet 75 91 Pump: Manufacturer's Name Type• Black medium sandy gravel,fine to silt 91 H.P. Pump intake depth: R. Designed flow rate: gpm sand,water 97 Water Levels: Land-surface elevation above mean sea level 76 ft. Gravelly clay,stiff,dry 97 119 Stick-up of top of well casing 15 fl.above ground surface Static water level 66 ft.below top of well casing Date 9/14/22 Black silty bound gravel,dry 119 136 Artesian pressure lbs.per square inch Date Black fine sandy silt,moist 136 145 Artesian water is controlled by (cap,valve,etc.) Black fine sand,heaving,silt 145 196 Black medium sand,tight,wet 196 203 Well Tests: Heaving black medium sandy gravel,water 203 218 Was a pumping test performed. t7 No 0 Yes => by whom. Yield gpm with ft.drawdown after hrs. Yield gpm with fl 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 level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test gpm with ft.drawdown after hrs. Air test 100 gpm with stem set at 200 ft for 1_hrs. ^ Date 9/14/22 Artesian flow gpm _ Temperature of water 50 °F Was a chemical analysis made? 0 Yes O No Start Date 12/13/22 Completed Date 12/14/22 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 E Driller 0 Trainee❑PE-Print a ogerav 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 12/14/22 ECY 050-1-20(Rev 09/18) lfyou 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. 4 • 01,9,20 ,Z2- 01574-1 1786 SE Mile HI11 Drive J1 Port Orchard,WA 98366 SPECTRA Laboratories www.spectra-lab.com w.spectra-Iab.com .e - ,w, „ie,...,,,,," (36O)443-7845 ENV 1 R O N M E N COLIFORM BACTERIA ANALYSIS FORM Data Sample(blleaed Time Sample County HEALTH 12 / 29 J 22 Colbded 3 5O w Mason em uene� Dry Year -- Type of Water System(deck only one box) ❑Group A ❑Group B EJlOther Group A and Group B Systems-Profile from Wader Farlltles Inventory(WFI): IDA Nam&LI Mellinger RECEl Corded Person:Arleta EIeil&Aroadla Drilling NY Phone:38G-418-3395 Cell Phone el:En arieteraercadiadrillIng.com Eve,Phone: Send results t:(Art 101 awns,atdresr and:facade a �ea I arletagarcadladrMing.com v * Arcadia Drilling,Inc BAN 1 0 2023 SAMPLE INFORMATION 615 W Salvia collected by(na,xi:max --- , ,glder Str�,t Speck location where sample oorieded: Special hWucfons a comments: •BNV828 251 E Big 8kookum Rd,Shelton Type of 8any(e(check only one box) 1.0 Routine Distribufon Sample 2.Remit Sample(after un sett roufne) Chlorinated:Yes❑ No❑ ❑Distribution System Chicane Residual.Total Free_ Unaatlsfadory routine lab number: 3.Decree Ground Water Rule Sample i g I J I Unsatistactay routlne collect date: El Triggered Chlorinated:Yes❑ No❑ ❑AResst Chlorine Residual:Total Free 4.Exoneration Scuts wafer Sangre 8 I I ❑E0oq ❑Fecal-outmost hyper:Nero Yaa❑ Ne❑ &Q Banpis Cabled for nAarnaeon Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Co iform Present and ySatisfactory _ ❑E.coDpresent ❑Emil absent Replacement Sample Required; ❑Sanpte too ad(>30 hours) ❑TNTC ❑ ----- Bacterial Density Resutts:Total Cdlfomi /100nd. Erne /100ml. Feat Coitus NPC._.. --- --- _r1 mi. Lao igtoer. f bf�Od Code' 1 J oats end I.,.kubehd: SM 9223 B DEC 3 0 2022 Date Anatyred Dery Repama: pp/210 •9 k•z13 i /1-2- V itiS•nad1 tab Use Or* n TAH ro+.m,�bl.�►.arh.ir�w.ii,r.+err*.ram+.. „r •,r e+r tvayn} ---- - m.r ry. n . r.wslR.aseryiry7,rr. I I Return To . ► YY1f I I,h . 2192587 MASON CO WA o\ -Y1'�Pl �. 01/09/2023 12.40 PM MOTCE ]�1� MELLINGER #183318 Rec Fee. $204 50 Pages 2 -Tatorvta 1 III III IIII 11 MI III 1 ill II IIII 1 11 1 IIIII II,III !1 III 11 1110111111 Grantor(s): (1) L I C 1 M e-'' f1Cj eQ. , (2) Grantee(s): (1) PUBLIC J Legal Description (1) LOT: C OF SP#629& 1/2 INT LOT: D S 4/139 S 41/88 S 41/108 (Abbreviated loan:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 2 2 0 2 0 _ 7 5 _ 9 0 0 9 2 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: 14 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this 4 4 L day of,I ()t n tia r y , 20 2 Signature of Grantor(s): / (1) `YV,/i?Id '1 , (2) State of Washington ) County of Mason ) 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 Lit day of jar)vt-6,v`/ , 20 L. 3 , L)c c,L,1./ e. I I I-e r 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 and year last above written. Notary Public in and for the State of Wasn, ""m ���P ZUN/C tit residing at s •••=as A?aq 'ice My commission expires: o /u7- � =o = A664 fiSH iuZZ03 v ue I. t' ''a 8_30;L�O $C9_ � �9 h.111%%\‘... �\ i11�'''`'1tOF\W Py,, Page 2 of 2