HomeMy WebLinkAboutWAT2023-00007 - WAT Application - 1/10/2023 ENVIRONMENTAL
HEALTH WAT apa - pan---7
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-� IZL_V I`/�E�j 415 N.6'h Street
MASON COUNTY
Shelton,WA 98584
�l• ' } COMMUNITY SERVICE8AN 1 0 2023 Shelton:360-427-9670,Ext.400
�i i''` Irz Belfair:360-275-4467,Ext.400
? � Buildng,Planning,Environmental Health,Community Health W. Alder Street Elma:360-482-5269,EXt.400
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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: K1,0- % i'itl. Wernakerk-- Vie
Mailing Address: ‘0`V-tD., \a\NA_Ave . J V Phone: 6..0 4 " M .,7
Parcel Number: 3a9.-5-7 5— o0190
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit a —60o ft.--7
connections) 0 Division of land:
'individual water source(one connection), #of Parcels? SPL
Well ❑ 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\ELIFoims\Drinking Water Revised 4/27,'2021
WATER WELL REPORT ()EPA MEN I OF Notice ofIntent No. WE49306
--—' ECOLOGY Unique Ecology Well ID Tag No. BNX274
type of Work: State of Washington
3' Construction Site Well Name(if more than one well):
L.) Decommission r Original installation NOI No. Water Right Permit/Cerlilicale No.
Proposed use: ill. Domestic ❑Industrial 0 Municipal Properly Owner Name Ean Hernandez
. 0 Dewatering 0 Irrigation 0 Test Well 0 Other
Well Street Address 1420 E Timber Tides Dr
Construction Type: Method:
L')Ness'well ❑Alteration LI Driven 0 Jetted 0 Cable Tool City Union Courtly Mason
0 Deepening ❑Other ❑Dug LC Air- ❑Mud-Rotary Tax Parcel No. 32235-75-00190
Dimensions: Diameter of boring 6 in.,to 520 n. Was a variance approved for this well? ❑Yes ❑' No
Depth of completed well 520 a.
If yes,what was the variance for'?
Construction Details: wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread
G3 I 0 6 in. 0 520 .025 in. l l I 0 O I 0 Location(see instructions on page 2): R WWN1 or 0 EWM
O 1 ❑ its. in. ❑ 1 ❑ ❑ 1 O SE Y-Y,of the SE 'Y,;Section 35 Township 22N Range 3W
❑ 1 O in. _ _ in. 0 1 ❑ ❑ I O❑ I 0 in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.348176
Longitude(Example:-120.12345) -123.018371 _
Perforations: ❑Yes O No Type olperforntor used
Driller's Log/Construction or Decommission Procedure
No.of perforations_ Size of perforations in.by in. formation:Describe by color,character,size of material and structure,and the kind and
Perforated front-It.to II.below ground snrlaee nature of the material in each layer penetrated,with at least one entry for each change of
Screens: ❑Ycs P3 No ❑K-Packer a--,' Depth n, inhumation. Use additional sheets if necessary.
Manufacturer's Name - Material from To
'type Model No. 16
Diameter Slot size in.from II to II. Brown silty sand and gravel 0
Diameter Slot size in.front Il to n. Brown sand and gravel with clay binder 16 27
Brown fine sand,gravel,light 27 46
sand/rater pack:❑Yes C•7 No size of pack material in Multicolored gravel,brown fine sand,silt 46 132
Materials placed front n.to_II. Multicolored sharp gravel,brown medium 132
Surface Seal: le1 Yes 0 Nu To what depth? 19 n. sand,loose 188
Material used in seal Bentonite Chips Brown fine sand,silt 188 201
Did any strata contain unusable water? 0 Yes (I No
Type of water? t)epth of strata Multicolored sharp gravel,brown fine sand,silt 201 275
Brown fine sand,silty 275 283
Nlethod or sealing strata off
Brown siltbound sand and gravel,tight 283 354
Pump: manufacturer's Name Type: Brown fine silty sand,tight 354 363
I l.l>. Pump intake depth: II. Designed flow rale:_spur Brown silty clay,hard 363 367
Witter levels: I,artd•surface elevation above mean sea level 530 (1, Brown silt - ------ 367 373
Stick-up of top of well casing 1 II.above ground surface Gray clay 373 379
Static water level 475 n.below top of well casing Date 11/21/22 Brown silty sand and gravel 379 382
Adesinn pressure lbs.per square inch Date Brown silt,tight 382 416
Aucsran water is controlled by (cap,valve,etc.)
Brown fine sand,some gravel 416 428
wen TcsLs: Multicolored pea gravel,brown fine sand 428 471
Was a pumping test performed? I!]No ❑Yes I---: by whom? Brown fine sand,few gravels,tight 471 501
Yield gpm with Il drawdown after _hrs.
Yield gpnr with_II.drawdown after hrs. Multicolored gravel,brown fine to medium 501
Yield spin.with_n.drawdown alter hrs. sand,water 520
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 __
Bailer test gpm with_ft.drawdown aver hrs.1
Air test 15 pm with stem set at 500 II.for 1 hrs. 1 Date 11/21/22
An„;„„Ilosv gpm
l'entperawrre ol'water 40-1: was a chemical analysis made? 0 Ycs E No Start Date 11/16/22 Completed Dale 11/21/22
\\'E1,1.CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction darts well,and its compliance with all Washington well
construction standards.Materials used and the intitrnmtion reported above arc true to my best knowledge and belief
AT Driller 0'Trainee 0 Pli-Print Name Josh oepp Drilling Company Arcadia Drilling Inc.
Signature '�/�� Address PO Box
1790
License No. 2874 City,State,Zip Shelton,WA 98584
IF'TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Dade 11/21/22
ECY 050-1-20(Rev(19/18) if you need this document in an alternate Prima,please call the Water Resources Program at 360 l07-6872.
Persons with hearing loss can call71l for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
1786 SE Mile Hill Drive
Port Orchard,WA 98366
^J` SPECTRA Laboratories-Kitsap www.spectra-lab.com
.�,..lF..Wee'WWI (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
12 I 5 / 22 2 00 CI AM Mason
Month Dry You m PIA_ _.._..—..--
Type of Water System(check only one box)
❑Group A ❑Group B pother _
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:Ean Hemandez
Contact Person:Arleta Eisele/Arcadia Drilling
Day Phone:360.428.339E Cell Phone:
Email: ariota@arcadiadrilling.com Eve.Phone:
Send results to:(Print full name,address and nip code a e•mat)
arieta@arcadiadrilling.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Max
Specific location where sample collected: Special instructions or comments:
#BNX274
1420 E Timber Tides Dr,Union __—
Type of Sample(check only one box)
1.0 Routine Distribution Sample 2.Repeal Sample(after unsat.routine)
Chlorinated:Yes❑ No❑ ❑Distribution System
Chlorine Residual:Total_Free_ Unsatisfactory routine lab number:
3.Source Ground Water Rule Sample —.—— —. ----—
S I I I Unsatisfactory routine collect dale:
l J
El Triggered Chlorinated:Yes CINo❑
Chlorine Residual:Total_Free,
❑Assessment
4. Enumeration Source Water Sample ISI I
❑E.colt ❑Fecal-Svrrhw,em,Sp'ngr.Ft end Yes Ho El
5.D Sample Collected be information Only:LAB USE ONLY DRINKING WATER RESULTS LAB U E ONLY
❑Unsatisfactory Total CoJBorm Present and atisfactory
❑E toff present ❑E.coli absent
Replacement Sample Required:
0 Sample too old(>30 hours) 0 TNTC .
Bacterial Density Results:Total Coliform /I00m1. E.coll _r/IOOml.
Fecal Coliform _J100ml. HPC_ /1 nil.
Lab ID Number _ —DaleanUEe fo ct e9n
13te05?)'u1 Ut
/LISiL,r,
Poihod Code: Dale and Time Incubated.
L/
SM 9223 B _!_ ( 2 ---
Date Analyzed: Date Reported:
DEC 7 2022 DEC 7 2021
DOH Lab•Sanrple# lab Use Only:
225 . 0 3 0 I
--
0011 i'anngl:J'Al if you radii.µlW.L'p�in md'�„•TL eddA.92i017 C Y/W711).
nil.rd:fw0lo.[cm is rro7.D2 al xna d,12w.4rdb4k,vain.
2193611 MASON CO WA
02/08/2023 11:12 AM NOTCE
HERNANDEZ #184134 Rec Fee: $204.50 Pages: 2
IIIIIII IIIIII 1 I III IIIII I►IIIII III 1 I IIIII IIIII IIIII I II 1111111111 III
Return To
Ean and Rebecca Hernandez
10542 12th Ave NW
Seattle WA 98177
Grantor(s): (1) Ean Norman Hernandez (2) Rebecca Eileen Hernandez
Grantee(s): (1) PUBLIC
Legal Description (1) TR 19 S 1/210-213, S 52/81 ,
(Abbreviated form:i.e.lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 2 3 5 _ 7 5 _ 0 0 1 9 0
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 Lk day of 1 k/t t� , 20 a'
•
Signatur rantor(s):
��I� 9 X.
(1) ���l �► , (2)
State of Washington •. 4
County of Mason
Page 1 of 2
I, the undersigned, a Notary Public i and for the above named County and State, do hereby
certify that on this � " day of Tr-- , 2073 ,
E /Rc -ccc,, J/rrna 6- onally 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 Washington,
�p,RA/1.y0t t 1/1 residing at 17)Z_A,UJ ►V+1 i-e 'T 910`7
•ss=55 A �'�,� /�� My commission expires: C>`Dy/702j
° 20115923
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