The URL can be used to link to this page

Home My WebLink AboutWAT2022-00304 - WAT Application - 11/3/2022 . WAT °OWL( MASON COUNTY c-NNIRMENT =` .lz) COMMUNITY SERVICES pN _�i .1I�, :, HE A may, w Building,Planning,Environmental Health,Community Health 415 N 6t"Street, Bldg 8, Shelton WA 98584, V ED Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 •:• Elma: (360)482ggeCx14 FAX(360)427-7787 NOV — 3 loll Application for Determination of Water Adequacy 615 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: 1 ` kki1 cam( Date: t C tC Mailing Address: �0 ��1 �A Vohs C r j Phone: 2(,c 0 L{q O (o( Parcel Number: a�J.QO( , _i?D r 9 'CC -,) Type of Water System Reason for Application q ❑ Public/Community Water System (2 or more �, Building permit �i 0 2-01 11-P connections) 0 Division of land: • Individual water source (one connection), #of Parcels? SPL D' Well 0 Boundary line adjustment O Spring/surface water ❑ Other(explain) El (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) O 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. O 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:\L•11 Forms\Drinking Water Revised 1/25/2018 Individual Water Well (l VS() �L,Water well report(attached to application). Depth ft. Well capacity Test (attached to application) (23-9 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. tli.\_ Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14� 15{ 116n 22n Water use or limitation recorded N/A n Yes Well Drilled . Date �I 11'C �. 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) 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. =1 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 of CSD Director: Date ,, or 1 • • 1 WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE51194 ECOLOGY Unique Ecology Well ID Tag No. BNH 822 Type of Work: WI State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial ❑Municipal Property Owner Name Megan Gould D Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 881 E Malaney Creek Rd Construction Type: Method: • E New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug El Air- 0 Mud-Rotary Tax Parcel No. 22006-30-92002 Dimensions: Diameter of boring 6 in.,to 135 ft. Was a variance approved for this well? 0 Yes O No Depth of completed well 135 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I ❑ 6 in. +1 130 .25 in. D I ❑ DID Location(see instructions on page 2): O WWM or❑EWM ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ NE %-''h of the SW A;Section 06 Township 20N Range 02 ❑ I ❑ in. in. ❑ I ❑ DID ❑ I 0 in. in ❑ I ❑ DID Latitude(Example:47.12345) 47.24937 Longitude(Example:-120.12345) -122.98300 Perforations: ❑Yes ❑O No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations in.by in. Driller's Describe by color,character,size of material and structure,and the kind and Perforated from ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑a Yes ❑No ❑� K-Packer l=> Depth 129 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Stainless Steel Model No. Diameter 5 in. Slot size .014 in.from 130 ft.to 135 ft. Sand,gravel,silt,brown/soft 0 46 Diameter iu. Slot size in.from ft.to ft. Sand,gravel,silt,some clay,brown/hard 46 79 Sand,silt,little water,brown/soft 79 100 Sand/Filter pack:0 Yes 0 No Size of pack material in. Sand,silt,little water,fine-hard layers of sand Materials placed from ft.to ft. brown/soft 100 128 _— Surface Seal: O Yes 0 No To what depth? 18 ft. Sand,gravel,silt,brown/soft,wb 128 133 Material used in seal Bentonite Granular Sand,brown/soft,wb 133 135 Did any strata contain unusable water? ❑Yes ENo Type of water? Depth of strata Clay,gray/soft 135 Method of sealing strata off Pump: Manufacturer's Name N/A Type: • H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing +1 ft.above ground surface Static water level 58 ft.below top of well casing Date 3/1/2023 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? O No ❑Yes b by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after_hrs. Recovery data(tune-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 30 gpm with stem set at 130 ft.for 1 hrs. Date 3/1/2023 Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes [7 No Start Date 2/28/2023 Completed Date 3/1/2023 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❑Trainee 0 PE-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling Signature C °h..:- .) (.7.---+y Address 1162 NW State 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 3/1/2023 ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 fANOUAP t), Report of Laboratory Analysis LABORATORY Collected by: Moerke and Sons Matrix Drinking Water 360-748-3805 Laboratory ID: V230314-3 Sampling Address: Date Sampled: 3/14/23 13:40 881 E Melany Creek Rd Date Received: 3/14/23 14:47 Shelton,WA 98584 Date Reported: 3/16/2023 Sample ID: Jake Gould Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform& E.coli by SM 9223B(IDEXX) Batch ID:V230314-3 Analyst:VJ Coliform,Total Negative I I MPN/100 ml_ 1 3/14/23 16:55 E.coil Negative I I MPN/100 mL 1 3/14/23 16:55 Nitrate by EPA Method 353.2 Batch ID:V230314-3 Analyst:RS Nitrate(as N) ND 0.50 10.00 mg/L I 3/15/23 11:00 • Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Robert Smalling,Chemist on 03/16/2023 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 03/16/2023 DF:Dilution Factor '��` 17025:2017 ��r ►ccacaaen MCL:Maximum Contaminant Level S �_ �� Page I of 1 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 DLO ao22- C\�l l C4 2193394 MASON CO WA E N TA L 02/01l2023 02:37 PM NOTCE HEALTH IIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIA�IIIlIlIII IS��b 20z3 Return To ENVI RO N M Meopn Lao( 1-30\ `� aka (V 615 W. Alder Street Grantor(s): (1) �A C.( , (2) ZbLeo ouId Grantee(s): (1) PUBLIC NE `3. .LJ Legal Description (1) OFSQ i-'2) 35 AFC 21`t a3QLk PTI\l (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) g a . _ D .- -.2_ .O_ 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: 9SO gallons Dated on this 4 day of NOV , 20 "2-2: Signature of Grantor(s): (1) ''YLia -- , (2) tn.>7 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 Linn day of NOVr.4°Y\Ipel' , 20 22 , Mcgtu'1 ar0 ow;019 if/bu.1d 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. V.,§cl.C(46 IA)&4 1! \\\��\c\\G.. .J.... -,/�/ Not(ry Puc in anr the Mate of Washington, \� C7� \salon :'". 0-+ ., resiain t MGtd Oln GO UVLt�i oh 2 12 �5: .Z: �; o• My commission expires: Nt G�-i '2-1 20'LS N: PUBOG o Page 2 of 2