HomeMy WebLinkAboutWAT2023-00030 - WAT Application - 2/2/2023 _, WAT 20,13 - 66
(rf\, MASON COUNTY RECEIVED
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health FEB 0 2 2023
415 N 6th Street, Bldg 8, Shelton WA 98584,Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (36� 1/1/9 Alggr Street
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: Daniel Hess Date: of — 8--26 Z 3
Mailing Address: +Es(y, 7 jQ a pL0 -r
Parcel Number: 31904-11-90010 0 5(k)
Kcx `..>-fx.c— LO A
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more a Building permit 3I c12O2 --volt-V-1
connections) 0 Division of land:
O Individual water source (one connection), #of Parcels? SPL
ID Well 0 Boundary line adjustment
❑ Spring/surface water
❑ 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)
❑ 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;20I R
Individual Water Well
Water well report (attached to application). Depth 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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planninq 1 15l 16=22=
Water use or limitation recorded N/A 0 Yes X<
Well Drilled Date V f((,, (Z2-
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
O 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)
1Satisfactory 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: c) ram4-6\✓, Date //I w
,of
CSD Director: Date
` c\ V-\•ess
Vanguard Laboratory
`ro4 2635 Parkmont Lane SW
Y.e @ Olympia,WA 98502
360.967.7010
VANGUA Report of Laboratory Analysis
LABORATORY L
Collected by:
Moerke and Sons Matrix Drinking Water
360-748-3805 Laboratory ID: V221013-3
Sampling Address: Date Sampled: 10/13/22 14:00
0 SE Ellis Rd Date Received: 10/13/22 15:20
Shelton,WA 98584 Date Reported: 10/14/2022
Sample ID: LOT 1
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.coli by SM 9223B(IDEXX) Batch lD:V221013-3 Analyst:VJ
Coliform,Total Negative 1 1 MPN/100 mL 1 10/13/22 16:00
E.coli Negative 1 1 MPN/100 mL 1 10/13/22 16:00
Nitrate by EPA Method 353.2 Batch ID:V221013-3 Analyst:RS
Nitrate(as N) 0.991 0.20 10.00 mg/L 1 10/13/22 17:45
Notes:
MPN:Most Probable Number
ppm:parts per million
nd:non-detect Reviewed by Robert Smalling,Chemist on 10/14/2022
n/a:not applicable
SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 10/14/2022
DF:Dilution Factor
girl. 17025:2017
?�l
MCL:Maximum Contaminant Level ��I.! TORACCRED Page 1 of 1
LABODA
Samples were recieved in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent
with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results.
2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com
www.vanguardlaboratory.com
•
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DEPARTMENT OF NotluoflntantNo.
WATER WELL REPORT 4 7
ECOLOGY Unique Ecology Well ID Tag No.
Type of Work: State of Washington
Site Well Name(if more than one well
Construction )
.
0 Deco+un rs on cy Original installation NOI No. Water Right Permit/Cernficato No
•
Proposed Use c9 Domestic 0 Industrial 0 Municipal Property Owner Name Dan Hese
°Dewatervng °Irrigation 0 Teat Well 0 Other Well Street Address 0 SE Ellis Rd,Lot 1
Construction Type: Method:
CountyMason
d'New.well 0 Alteration 0 Drivnn ❑Jetted 0 Cable Tool City Shelton
°Deepening ❑Other ❑Dug tEl Air ❑Mid-Rotary Tax Parcel No. 31904-11-90010
Dimensions:Diameter of boring 6 in,to 78 ft.
IMpth (completed
Ieted well 78 ft. Was a variance approved for this well? 0 Yes CI No
trued.Details: Waft If yes,what was the variance for?
Casing Liner Diameter Front To Thickness Steel PVC Welded Thread
GI ❑ 6 in. a1.S 78 .25 in. t7 1 0 0 1 0 Location(see instructions on page 2): 17 WWM or 0 EWM
Q I ❑ _n. _in. ❑ 1 0 0 I 0 NE '/e-1/4 of the NE '/.;Section 04 Township 19N Range 03
❑ 1 ❑ —in. _ _ _in. ❑ 1 ❑ ❑ 1 ❑
❑ I 0 in in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.16870
Perfontiom: ❑Yes O No Type ofpertorntor used Longitude(Example:-120.12345) -123.05634
No.of perforation Size of perforations in.by Driller's Log,�CotsstrucGoo or Decommission Procedure
Perforated from ft.to_IL below ground surface Formation structure,by color,character,size of material and scture,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: O Yes 0 No G K-Packer b Depth 72 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type Stainless Steel Model No. 0
Diameter 5 in. Slot size .016 in from 73 ft.to 78 ft. Top soil,gravel
Diameter_ in. Slot size is from ft.to ft. Sand,silt,some gravel,brown/soft 1 37
Sand/Filter pack:0 Yes IC No Size of pack material in Sand,gravel,silt,brown/hard 37 55
Materials placed from ft.to ft. Sand,gravel,silt,brown/hard,wb 55 76
Surface Seal: 17 Yes 0 No To what depth? 18 ftSand,less gravel,silt,brown hard,wb 76 79
Material used in seal Bentonie Granular
Did any strata contain unusable water? 0 Yes 21 No
Type of water? Depth of strata
Method of sealing strata off
Pump:Manufacturer's Name N/A Type:
ftP. Pump intake depth: R Designed Dow rate:_gpm
Water Levels: Land-surface elevation above mean sea level ft.
Stick-up of top of well casing +1.5 ft.above ground surface
Static water level 39 ft.below top of well casing Date 8/16/2022
Artesian pressure lies per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? E.No 0 Yes i=> by whom?
Yield_gpm with ft drawdows alter_hrs.
Yield gpm with ft.drawdown after hrs.
Yield_gpm with_ft.drewdown after hrs. _ _ _
o —water level meas'taafrom wen
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 45 gpm with stem set at 77 ft.for 1 hrs. Date 8/16/2022
Artesian flow gpm
Temperature of water_e F Was a chemical analysis made? ❑Yes O No Start Date 8/16/2022
Completed Date 8/16/2022
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.
O Driller 0 Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature C'e _a. . Address 1162 NW Stale Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 8/16/2022
ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at
360-407-6871. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call
877-833-6341.
2193475 MASON CO WA
02/03/2023 11:00 AM NOTCE
DRNIEL HESS #184020 Rec Fee: $204.50 Pages 2
1I.IIIIII111I1IIIIIHEM IIIIIIIIII II IIIII IM0 IIVIIIIIII
Return To
Da1)Ik�..} �,�, RECEIVED
Ucrrc �� FEB 0 2 2023
�rr,l�r t:e,r LA `165 `1
615 W. Alder Street
Grantor(s): (1) 1,7 4Q ILL •fA-Y1 , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) Lo.I- 1 I I AF {- ZILt i 5t!
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) .3 i '1 G - I I - I U C) I b
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: I
Maximum Annual Average Gallons Per Day: i 50 gallons
Dated on this day of re , 20 Z .
Signattfr of Grantor(s):
(1) \I , (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 anA day of F4braarl 20 aL 3 ,
�Gt ri 1 2 r.4 i 14-on Wf,55 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.
LETICIA MORALES Notary Public in and for the State of Washington,
NOTARY PUBLIC
STATE OF WASHINGTON residing at T 1,u►^5 0 rl
1 License Number 22030594
M COMmission Expires Dec.16,2025 My commission expires: Le c, ((a / „7.0�5
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