HomeMy WebLinkAboutWAT2023-00027 - WAT Application - 1/31/2023 WATaoa-5- 0003,1
ENS p,, ' MASON COUNTY
11I '1 COMMUNITY SERVICES
p� rh, 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)482- 6Next.10('1L,7
FAX(360)427-7787
Application for Determination of Water Adequacy
VV. 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.
14. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Keith Stephenson Date: 1/3 t/2( R-5
Mailing Address: 1737 Gregory Way, Bremerton, VPhone:850-786-7940
Parcel Number: 221167790041
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑ Building permit 122(✓0 ROR-3-60t-'Jl
connections) 0 Division of land:
p Individual water source (one connection), #of Parcels? SPL
O Well ❑ Boundary line adjustment
0 Spring/surface water
❑ 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 ReviseJ I/251201X
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://gis.co.mason.wa.us/planninq 14(W15U 16022U
Water use or limitation recorded N/A11 Yes I
Well Drilled Date l Si 9 sct7
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: Date 2 L F " 7013
2"''
CSD Director: Date
?LQO -of I 3\
1 1786 SE Mile Hill Drive r s--
Port Orchard,WA 98366 r f r
SPECTRA Laboratories-Kitsap wvnvw.spectra-lab.com
„AO or."°'r'""1.0111
°""' (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM (—F' LOLJ
Date SampleCaileded Time Sample County Alder Street
1 f 27 / 23 DAM 00 Mason 615 V�I
Will Ya Gs 12 .®PM
WillType of Water System(check only one box)
❑Group A ❑Group B ao�� ENVIRONMENTAL
Group A and Group B Systems-Provide from Water Fealties Inventory(WA):
I0f1 HEAD-H
System Name: Keith Stephenson `Z�3
Contact Person:Arleta ElselelArcadia Drilling I� Feb
Day Phone:360-426 3395 Cell Phone:
Email: arleta@arcadiadrilling.com ( Eve.Phone:
Send results b:(Prhl full name,address and zip code or e-mai)
arieta@arcadiadrilling.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Seth —-
Specific location where sample collected: Special hsbuctions or comments:
10 Keyhole Court,Grapevlew
Type of Sample(check only one box)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes❑ No❑ ❑Distributfcn System
Chlorine Residual:Total_Free_ Unsatisfactory routine lab number:
3.Source Ground Water Rule Sample
S f I Unsatisfactory routine collect date:
❑Triggered Chlorinated:Yes❑ No❑
❑Assessment Chlorine Residual:Total_Free_
4 Flxsmeraeon Source Wales Sample I
.S
❑E.coif ❑Fecal-Surface,GWI,SpFgs Faired Yea El No0
5.0 Sample Collected for Information ordy:T..
LAB USE ONLY DRINKING WATER RESULTS LAB U E ONLY
O Unsatisfactory Total Collfom Present and tlsfactory
0 E.coli present O Ecotabsent
Replacement Sample Required:
D Sample too old(>30 hours) 0 TNTC ❑_-__
Bacterial Density Results:Total Cafrorm- /100m1.E.colii .�1100m1.
Fecal Coiform _f100m1. HPC_. _/1 ml. y{,�C)
Lab ID Number Date and Tlme Received.
1J`/
13?0' 7-6\ -- JAN272023
Method Code: Dale and Time IrF e2 7 mj3
SM 9223 B ,If111 L cva
Date Analyzed ;AN 2 20, Dale Reporto 2' 202,
DOH taus t.eb lee "Ir.
225 .
OCM rewMt.3t OKA..om am) npotinpotk,tle,N an Ontsnnkdltia.9tialit'(l�tTy'id n
llir,ro4s;4k-si....ni,d,AN..doh wcplarinkgrisler.
.... _____ ,
ENTAL
, -.),L03025 ___0 0 1.-b
ENVIR� TN surf care No. W 099022
Fee Department
of Ecology rhtgin and Float Copy with HEAL WATER WELL REPORT UNIQUE WELL t.D.• ACY 266
De
Second Copy-Ownar'.Copy STATE OF WASHINGTON Weer Flight• Third Copy-DrIller'.Copy
C. (1) OWNER: None Dave Coleman Add. E 10 Keyhole Ct., Grapeview, WA 98546
w
re (2) LOCATION OF WELL: Cowl),
Mason SE va SE Iw see 16 T. 21 N,fi 2W weed.
l (2s) STREET ADDRESS OF WELL of nearest seem' E 10 Keyhole Ct., Grapeview, WA 98546
• (3) PROPOSED USE: `- Domestic Industrial :0 Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
N :1 Irrigation Test Well C Other C Formation: Describe by color.character,size of material and aructure,and show thickness of equates
C DeWater and the hind end nature of the material In each stratum penetrated,with at least one entry for each
change of irtbrrreton.
4'4 (4) TYPE OF WORK: Owners number d well FROas TO
O Abandoned 0 New well l Method:Dug 0 Bored(I
Deepened C Cable EX Driven 0
O 0 .T 0 5
O Reconditioned I.I Rotary Jetted C Brown conglomerate
R (5) DIMENSIONS: Diameter of wet_ 6 inch... 5 45
E Drilled 74 feet. Depth of completed well- 74 - n. Brown hardpan
O (6) CONSTRUCTION DETAILS: Brown sand 45 57
CCasing installed: _ ..6 Diem.horn0- -n.to_ 64 n. _
Welded IS • Diem.from It to Threaded ❑ • f< Sand & gravel with water 57 74
a) Liner instated C Dem.from .-_It.to ft.
- - SECCIV
0
Perforations: Yes ❑ No
n?Type of perforator used _ - f ♦ y--�
C• SIZE of pedorationi in.by In. 1 �
fL to ft.
Cu perf�rfo o from _ - 5 W A►der Strut LA
from R.to n. �1 -� ...
Ca perloratbne room n.to n
r
Type Screens: Yes® NO 0 _
-13
-C Mantel t rer'a Name - -_ Cook . - - �— t,1T
+� Type stainless wire wrap_ tAodel No._-- . t,
yam. own. 5 slot size 30 from 64 _n.to 69 n.
73
clam. 5 Sbt size 25 from 69 _n.to 74 fL ��
Cu l
CU 0 size d ravel '-_ �i
h- Gravel pub: Yeallo
R n.to x•
Gravel placed from --
or
Surface seal: Yes L No 0 To what depth? 18 ft.
O Material used in seal Betpni to r-t -
in - -
z Did any strata contain unusable wafer? Yes 0 No L3
(A Type of water?_ Depth of strata-
OMethod of sealing strataft - -o _-- - - _
T (7) PUMP: Manufacturer's Name-- - - .- - - -
N-P
0) Tyw: - -- -- - - - _ -- 913/97
O work stwted .19- Condetu _.9/J 7. 19
(B) WATER LEVELS: 1 en0 sO`t1°°� dbO" _ n
O above mean see level-- - - -_
0 static levet .57 _ h.beaw top of well Dam_. WELL CONSTRUCTOR CERTIFICATION:
LU Mnun pressure es.per square Inch Dale .
I constructed and/or accept responsibility for contraction of this wet, and its
4- Artesian water a controlled by (so,valve.arc- compliance with all Washington well construction standards. Materials used and
O TESTS: amount water level is lowered below static the information reported above are true to my best knowledge and belief.
�n• (9) WELL Drawdown is level nt�,,,
made?Yes❑ No El If yes.by whom? NAME _-_D_aYis- -o�Aa+T--
U Was a pump test hes. mason. t w. oavawd�i R`roF
EYield: gal./min.with -ft.drawdown after
L „ „- „ddmSB Belf air WA 98528
Cu „ — "� License No. 1884
CB rned of)(water level measured from well (S ) --
Recovery deter(t me taken es zero when pump N
top to water level) Water Level
fy Time Water Level Time Water Level Time Contractor's
- - - - n
No. DAVTSDT11 ODA -Data—Sept. ,19 97
(USE ADDITIONAL SHEETS IF NECESSARY)
Date of teat -
�+ tt.drawdown after 1 -ws. Opportunity and Affirmative Action employer.For ape
13su ter teal 9 gal./min.with Ecology Is an Equal Oppo y
Airtest gal./min.with stem set at- -x.for- fors' cial accommodation needs,contact the Water ResOurceS Program at(206)
Artesian flow -g.p.m. Date 407-6600,The TDO number is(206)407-6006-
Temperature of water-- _Was a chemical analysis made? Yes❑ No
ECY 050.1-20(9.931'•r
I7D
b1)9
• C I�` �-- SOW and No. W 0990122
Department
rtment tEcolo Co - WATER WELL REPORT UNIQUE WELL LD.e ACY 266
SewnC py— a 'e copy JAN 3 1 2°43 STATE OF WASHINGTON Water Right permittb
Thlyd Copy—Drtllen'e Copy
(1) OWNER: Nrrr Pteek.Pt011bireet Adaees E 10 Keyhole Ct., Grapeview, WA 98546
(2) LOCATION OF WELL: county Mason . SE 1t4 SE 1/4 Sw 16 T 21 N_,n 2W W.".
(2a) STFMMTADDRESSOFWELLornftmaacomio E 10 Keyhole Ct. , Grapeview, WA 98546
(3) PROPOSED USE: [X Domestic Industrial C Municipal n. (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
U Ism^ Test Well C OtherFormation: Describe by a andthickness
r,character.size of material and structure.a show thiess of awaking0 De Water ❑ m
and the kind rind nature of the material In each stratum penetrated.with at feast one wiry for each
(4) TYPE OF WORK: Owner's number of well change of.nIo on.
(h more ttnan nX1a) -- ____ UAW MOM TO
Abandoned ❑ New well 7F Method: Dug❑ Bored 7
Deepened ❑ Cable❑C Driven 0
Reconditioned❑ Rotary C Jetted'❑ Brown conglomorate 0 5
(5) DIMENSIONS: Diameter of well 6 inches.
Drilled 74 feet. Depth a completed well 74 it. Brown hardpan 5 45
(6) CONSTRUCTION DETAILS: Brown sand 45 57
Casing installed: 6 • Diem.from 0 it.b 64 ft.
Weatied�Uledo Deft from " to " Sand & gravel with water 57 74
Threaded C • Dorn.from ft.to h.
P. rations: Yes El
d ENTP.�
Type ofperiondor used ENV IRO
N M
SIZE of perforations in.by in. 1 •
perforations from ft.to ft. HfA 1..I H
perforations from ft.to h. ��j/ 1 ,,•,
perforations from ft.to ft.
�2 n, rr
Screens: Yes ® No -o
Mans rsrs Name Cook9P -
Type stainless wire wrap Modal ll""v i No. t�r Ul
Dian'. 5 _sot size 30 from 64 tit.to 69 ft
Diem. 5 siet sa. 25 from 69 e.to 74 tit.
Gravel peeked: Yes CI No ® Size of gravel - .� t'�
Graved placed from ft.to ft.
Surface seal: Yes 51 No❑ To what depth? 18 ft.
Material used in seal Betonite
Did any strata Domain unusable water? Yes ❑ No [a
Type of water? Depth of strata
Method of setting strata of
(7) PUMP: 114anut cturer's Name
Type: H.P.
(8) WATER LEVELS: -ocnace' n Work Started 9/3/97 19. cettht>'•ted 9/5/97 19
show mean sw ksvet__ ft.
Static lave( 57 e.below top of weal Dale
Artesian preeetae lose per square inch Dale
WELL CONSTRUCTOR CERTIFICATION:
Meow water Is controlled by I constructed and/or accept responsibility for construction of this well, and its
(map.valve.etc.) compliance with as Washington wee construction standards.Materials used and
level is lowered below static Tavel(9) WELL TESTS: Dewclaw is amount water the information reposed above are true to my best knowledge and belief.
Was a pump test made? yes 0 No® It yes,by whom? NAME Davis Darlaw
Yield: gal./mint.with _ ft.drawdown after hrs. (PE COnroathere MOE Ott seen
•• .. " •• Address Belfair WA 98528,� �
Recovery data(time taken as zero when pump turned of)(water level measured from wee (Sg�) Li w w,� 1 r License No. 1884
top to water level)
Time Water Level Time Water level Tens Water Level Contractors
No.R
n
o DAVTSDT1100A Date Sept. 19 97
(USE ADDITIONAL SHEETS IF NECESSARY)
Data of test
Bailer test 9 gal./min.with 4 ft.drawdown after_ 1 hrs.
Airtest gal./min.with stem set at ft.for hrs. Ecology is an Equal Opportunity and Affirmative Action employer. For spe-
} .r -, ;, ` n n' •,., •z,, ., '' tk i r.ial accommodation needs,contact the Water Resources Program at(206)
T e'of)), it r rna6ii i f Hilo 4 °N407-6600.The TOO number is(206)407-6006.
Printed from Mason County OMS
ECY 050-1-20190931••t