HomeMy WebLinkAboutWAT2022-00325 - WAT Application - 12/13/2022 WAT aoaa— oba5"
e MASON COUNTY
i N r ENTP, ~ COMMUNITY SERVICES
HEALTH
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)48 `l+ t:0
FAX(360)427-7787
L)EC 1 3 2022
Application for Determination of Water Adequacy
15 W. Alder Street
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: gfil h�+J�^ Date: ()ex _/ C 2
Mailing Address: S P--S S C 12A Phone: 2-53 - 3?-Li -oao"?
Parcel Number: 2 J)30 .-36- 0 Lio30
Type of Water System Reason for Application --��
❑ Public/Community Water System (2 or more l�• Building permit �` �p�,0a�`�V// lL.9
connections) 0 Division of land:
<IIndividual water source (one connection), #of Parcels? SPL
'ELVWell 0 Boundary line adjustment
0 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
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
Individual Water Well
Water well report (attached to application). Depth I 30 ft.
+Well capacity Test(attached to application) ` V
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.
)4. Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14'15U 160220
Water use or limitation recorded N/AJIYes
Well Drilled Date k\ 1-1 e
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.
0 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: V Date 2(?)(Z�
2 of?
CSD Director: Date
r
ENVIRONM`N 6LO oZba,off _ 0 (5J
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0 WATER WELL REPOR A LT H CURRENT ��C E \,�`
Original&1"copy-Ecology,2m copy-owner,3n1 copy-driller Notice of Intent No. WE40545 V
DEPARTMENT Or
ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. BKY-917 DEC 1 3 ZU21
❑■ Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION G15 W. Alder Street
Notice of Intent Number Property Owner Name Brian Vanduyn
PROPOSED USE: IN Domestic 0 Industrial 0 Municipal Well Street Address 5254 SE Arcadia Rd
0 DeWater 0 Irrigation ❑ Test Well 0 Other
City Shelton County Mason
TYPE OF WORK: Owner's number of well(if more than one)
l New well El Reconditioned Method:0 Dug 0 Bored El Driven
Location �yl/4-l/4 SW I/4 Sec Twn 20 R O2W EWM ❑
0 Deepened IN Cable 0 Rotary 0 Jetted (s,t,r Still REQUIRED) Or
WWM IN
DIMENSIONS: Diameter of well 6" inches,drilled 1'il' fl. Lat/Long
Depth of completed well 129• ft. Lat Deg - Lat Min/Sec
CONSTRUCTION DETAILS Long Deg Long Min/Sec
Casing IN Welded 6" " Diam from +1.5 ft.to 125' ft.
Installed: ❑ Liner installed " Diam.from fl.to ft. Tax parcel No.(Required) 220303004030
0 Threaded " Diam.From ft.to tl
Perforations: ❑ Yes ❑� No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of perforator used Formation:Describe by color,character,size of material and structure,
and the kind and nature of the material in each stratum penetrated,with at
SIZE of perfs in.by in.and no.of perfs_from_ft.to ft. least one entry for each change of information. (USE ADDITIONAL
Screens: 0 Yes ❑ No lifl K-Pac Location 123' SHEETS IF NECESSARY.)
Manufacturer's Name Johnson MATERIAL FROM TO
Type S.S.V-wire Model No. 304SS brown clay 0 2
Diem 6"rde Slot sin 14 from 129' ft.to 124' ft. light brown clay bound gravel 2 19
Diam. Slot size from ft.to ft. grey silt 19 28
Gravel/Filter packed: ❑ Yes ll No Size of gravel/sand grey silty sand 28 34
Materials placed from ft.to ft. grey silt 34 36
Surface Seal: II Yes ❑ No To what depth? 18' ft. grey clay 36 42
Material used in seal ""benru.ueDWp, grey clay bound sand/gravel 42 57
Did any strata contain unusable water? 0 Yes ® No brown silty sand/gravel 57 61
Type of water? Depth of strata grey silt bound sand/gravel 61 81
Method of sealing strata off grey silty sand w/wood 81 83
PUMP: Manufacturer's Name Grundfos grey til 83 121
Type: Sub. H.P. 3/4 hp grey silty sand-trace h20 121 126
WATER LEVELS: Land-surface elevation above mean sea level ft. clean sand/gravel 126 129
Static level 104.4 ft.below top of well Date 11/17/21 clay bound gravel 129 131
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump test made? 8 Yes 0 No If yes,by whom? Bison
Yield: 10 gal./min.with 14.4 ft.drawdown after 1.5 hrs.
Yield:_gal./rui&with ft.drawdown after hrs.
Yield: gal./min.with ft.drawdown after his.
Recovery data(time taken ac zero when pump turned off)(water level measured from
well top to water level)
Time Water Level Time Water Level Time Water level
Date of test
Bailer test 6 gal./min.with 10 ft drawdown after 1.0 hrs.
Airtest gal./min.with stem set at ft.for his.
Artesian flow g.p.m. Date
Temperature of water Was a chemical analysis made? 0 Yes 0 No Start Date 11/02/2021 Completed Date 11/17/2021
4 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.
4 ®Driller❑Engineer El Trainee Name Darrell Feavel Drilling Company Bison Well Drilling
Driller/Engineer/Trainee Signature Address PO Box 5142
Driller or trainee License No. 2398 City,State,Zip Spanaway,WA 98387
IF TRAINEE:Drillers License No: - — Contractor's
Driller's Signature: ' _ � Registration No. BISONWD945R9 Date 11/30/2021
ECY0S0-1-20(Rev 02-2010) To requertADA accommodation including materials in a format for the visually impaired,call Ecology Water Resources Program
at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341.
MIIIIIIMIIIMIIIIIMIMInik
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Thurston County Environmental Health i O V -t._..i
011 2000 Lakeridge Dr.SW 4 Olympia,WA 98502
—":-� 360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
I I Collected RECEIVED
S n AM 1
Mont Day Year • CIPM = :W.
^Type of Water System(check only one box) ❑ Private-Household
ElGroupA ❑Group B EI Other 1 ' •'.: ; ,' 61 AirierG Sin t
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
r- Contact Person: j
I Da Phone: L. •4V1RONMENTAL
y ( ) Cell Phone:( ) HEALTH
f r E mail:` i,tiu iri ?tt \,1;:"'r ' `. Eve.Phone:( ) i
Send results to:(print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name):
Specific location or address where sample collected: Special instructions or comments:
Type of Sample(must check'only one box of#1 through#4 listed below) IIi
I ' 1.®Routine Distribution Sample._ .►-2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total Free_ Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.col i-GWR(NP) ;
❑Fecal-surface,Gwi,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No ..
ElAssessment Monitoring(NP) ——— j
•
Unsatisfactory routine collect date: j
❑Other
/ /
S
4.❑Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and Satisfactory
0 E.coli present 0 E.coli absent to Worm detected •
•
° Replacement Sample Required:
If 0 Sample too old(>30 hours) ❑TNTC 0
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Colifoml /100m1 Enterococci /100 m1.
Method Code: M 9223B OSM 9222D Date and Time Received:
�S
. ❑SM 9215E 0 Enterolert0 i 7-4 . 7 IOW
Date and Time Analyzed: I • / 1 • I Date Reported: ('d5•9 ;t5 j
Sample Number(DOH number plus five digits) j
0 8 0 � Lab Use Only: � �l
�-
( DOH Form it331J19(revised 01/16)r
k HOC, �3 3o 1
dMEMEMMrre
2191732 MASON CO WA
12/13/2022 10 09 PM NOTCE
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!srUNIVOi ENVIRONMENTAL GC AV RECEIVED
1}eA Wh HEALTH DEC 13 [Ulz
615 W. Alder Street
Grantor(s): (1) 1 cA
Grantee(s): (1) PUBLIC /
Legal Description (1) �� 5 of-- 6 Vl/ 1 / 9 i3OT?O )2-a .
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1)JZ,t)3 .� -a O .- 0 H
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: - 9.5D gallons
Dated on this 13 day of Dec , 20
Signature o
(1) (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a *Wry Public in and for the above named County and State, do hereby
certify that on this 13 day of De c�nbe4t , 202Z
NictiA 0kY 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 ear last above
Notary Public • , /r
State of Wasklle$toot Notary Public in and for t :te of Washington,
ARIANE M PAYSSE residingat Ma Co
MY COMMISSION EXPIRES w
i2/29/2025 My commission expires: 12I24/7025
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