HomeMy WebLinkAboutWAT2023-00035 - WAT Application - 2/13/2023 ..rN`,. rr_,.11 I W AT af( - O�S
a1 :A,, MASON COUNTY ���,��
!` COMMUNITY SERVICCr.--
,, 4.` Building,Planning,Environmental Health,Community Health F L R 1 3 LO[
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 °: Elma: (ittfgW,561claktFaireet
FAX(360)427-7787 ENVIRONMENTAL
Application for Determination of Water Adequacy HEALTH
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:6742y-t-D/ANHA 6011/7Cir- Date: / ?/ Z 3
Mailing Address: 703/ S A/2C-4-blit 72,,,G Phone: 140-1/41 0077
Parcel Number: 22.6.,2 x 75— UO92-i->
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ia, Building permit 61.1330a3-00173
connections) 0 Division of land:
't: Individual water source (one connection), #of Parcels? SPL
la Well 0 Boundary line adjustment
0 Spring/surface water 0 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 1,25/2018
Individual Water Well
[[A Water well report (attached to application). Depth 670 ft.
En" Well capacity Test(attached to application) 3c) 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
y a licensed contractor.
Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http:!!gis.co.mason.wa.us/planning 1,all 15U 160 220 t
d
Water use or limitation recorded N/A D Ye #
3
Well Drilled Date 9"/- 2-2—
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
O 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: / /�7
Environ. Health:
1 __.2 Date )l z>1 G//Z?
CSD Director:
Date 2 of 2
e) �3- ooITh
• " '+� �� � ��4
ENVIRONMENTALEIVED
)rig 1 3 2023 H EAL t H OCT 17 2022
fole
WATERNI/ L O t I11311 DE PAR
FMFN'. OF Notice of Intent No.WE49246 WA State fldpatLinent
ECO LOGY Unique Ecology well ID Tag No.BPN 015 of Ccok:gq-(SWf�O)
Type or Work: hale of Washington
R Construction Site Well Name(if more than one well):
Li Decommission r—. Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: J Drarrnstie U Irduarial 0 Municipal Property Owner Name Diana Conner
❑Dosvatenng ❑Irrigation U'fcst Well U Other Well Street Address 7031 Arcadia Rd
Construction Type: Method:
X New well ❑Alteration D Driven ❑Jelled 0 Cable Tool City Shelton _-_ County Mason
❑Deepening I 1 Other D Dug T Air- ❑Stud-Rolaiy Tctx Parcel No.220087500020
Dimensions: Diameter of boring 6 in.,to 90 0. Was a variance approved for this well? ❑Yes O No
Depth of completed well 90 fl.
If yes,what was the variance for?
Construction Details: watt
Casing liner Diameter From To Thickness Steel PVC Welded Thread
R I C7 6 in. +2 85 .25 in. O I 0 O I 0 Location(sec instructions on page 2): O WWM or 0 EWM
U I 0 in. -- -- i s. ❑ I ❑ DID NE YrY.of the SE Vr;Section 29 Township 20N Range 2W
I I I I.I in. _ _ in. HID ❑ I ❑
U I LI in. in. L3 I ❑ ❑ I ❑ Latitude(Example:47.12345)47.194319
Longitude(Example:-120.12345)7122.953590
r_
o Perforations: U Yes J No Type of perforator used
Driller's Log/Construction or Decommission Procedure
t)) No.of perforations Sin ofpsrfurations in.by in.
Pei rotated horn—fl to 0.beIUN•ground swine Formation:Describe by color,character,size of material and structure,and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
ea Screens: M Yes D No 0 K-Packer - Depth 83 0. information. Use additional sheets if necessary.
I Johnson
y Manufacturer's Nonce Material From To
t Type Stainless Model No. Clay Loam Gravel 0 5
4- Diameter 5 in. Slot sue 16 in.from 85 ft.to 90 0.
0O Diameter in. Slot size in.from ft.to_IL Clay Gravel 5 20
Blue Clay 20 30
o Sand/Filter pack:0 Yes �i No Size of pack material in. 30 50
O Materials placed from tl.to fl. Clay Gravel
Brown Sand WB 50 70
Surface Seal: A Yes 11 No To what depth?19 0. Gray Sand WB 70 80
0L Material used in seal 318 Bentonite Chip
4— Gravel Sand WB 80 92
•— Did any strata contain unusable eater? U Yes d No
L. Type of water? Depth of strata —
0
lo Method of sealing strata off
Pump: Manufacturer's Name Type:
C I1.P. Pump intake depth: ft. Designed flow rate: gpm
O ..
n Water Levels: Land-surface elevation above mean sea level ft.
ed Stick-up of top ot-well casing i2 ft.above ground surface
t Static water keel 31 0.below top of well casing Date 09/02/2022
Artesian pressure lbs.per square inch Date — - --- _-- —_
C Artesian seater is controlled by ._-____(cap,salve,etc.)
O
L Well Tests:
3 Was a pumping test perfotmed? It No U Yes by whuos? --- ---- —_
i-• Yield gpm with 0.drawslown after hrs
O Yield gpm with_ft drawdown after hrs -
2 Yicld gpm with ft.drawdown after hrs. ..
in Recovery data(tine--let,)when pump is turned otT-water keel measured from well _
otop to water level)
Time Water Level Time Water Level Time Water Level
0
0
11J Date of pumping test
o Bailer test gpm with 0.drawdown after_hrs.
Air test 30__gpm with stem act at 90 ft.for 3 hrs. Date 09/0 212 02 2 _-- —
y Artesian flow gpm
t Temperature of water •F Was a chemical analysis made? U Ycs U No Start Date 09/01/2022 Completed Date 09/02/2022
r_
a. WELL CONSTRUCTION CERTIFICATION: I coustnteted and/or accept responsibility for construction of this well,and its compliance with all Washington well
to a construction standards.Materials used and the information reported above arc taste to my best knowledge and belief.
at
es-F Ill Driller n r e❑PE=Pr'it Name Robert Laymon Drilling Company Advanced Drilling LLC
Si nature Address 11530 School Land Rd SW
License No.2588 City,State,Zip Rochester WA 98579
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No,ADVANDL804DL Date 09/12/2022
ECY 050-1-20(Rev 08/19)/Ltyotr aced this document in an alternate format.please call the linter Resources Program at 36U-407-6872.
Persons with hearing loss can call 71l for Washington Relay Service. Peraaus with a speech disability can call 877-833-6341.
Thurston County Environmental Health I
t let 2000 Lakeridge Dr.SW •Olympia,WA 98502
v*
• 360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
_ Collected
artr - Dia.a., , I , I .2.3 _ DAM
Mcntb Day Year S FM '111 cp... Q n
0 'n /�Q Type of Water System(check only one box) ]'Private Household ,
01 { ' ❑Group A ❑Group B ❑Other
Group A and Group B Systems-.Provide from Water Facilities Inventory(WFI):
ID# •
IA 2DZ - V n 1i System Name:
Y 11 P61 Contact Person ‘cmy ro n,o ,c,
Day Phone:( o) 1-4-0o\ 0 0 —1-1 Cell Phone:( )
E-mail:Av.C;\A '.)1.„.11. C-'P.cm.,cJ,r1.Q.,",Eve.Phone:( )
Htv.nr i
Send results to?(Print full name,address and zip aide or email address)
--U'CL v (2.0v,ne r'
—ir--�1 �LC�scnrL..� hc�
SAMPLE INFORMATION
i Sample collected by(name):.. .
\C- Y-1(1.�C);1 VW_r
Specific location or address where sample collected: Special instructions or comments:
>>\ jtar�t(Ita
41 J1-)tit}c)r`, l.V{- `1?55?-i-
Type of Sample(must check only one box of#1 through#4 listed below)
0 1,:0 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.coli-GWR(A/P)
• ❑Fecal-Surface.Owl.springs(numerabcn) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(ANP) Unsatisfactory routine collect date:
❑Other 1 1
S
4.0 Sample Collected for Information Only
Investigative Construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and " Satisfactory
ElE.coli present ❑E.coli absent No Coliform detected
F f
!! Replacement Sample Required:
3• Cl Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. .E.coli 1100m1. -II
Fecal Coliform 1100m1 Enterococci /100 ml.
( Method Code:,❑SM 9223B ❑SM 9222D Date and Time Received:G'
❑SM 9215E ❑Enterolert® --) -23 cF, ,
• ( Date and lime Analyzed: •2. - `1 - 2 Date Reported. -2. 3A.F- 11
l Sample Number(DOH number plus five digits) Lab Use Only: i
0 8 0 L 4 -
Form-3#331.319(revised 01116) �_ "7
Z - 0 �,�
OW
2194996 MASON CO WA
03/17/2023 03.46 PM NOTCE
DIRNR CONNER #185195 Rec Fee: $204.50 Pages: 2
I llllill IIIII Ii 111/11111 IIIII IHI Ii IIIII IIDI III I I III IIUI.IIIII III ill
Return To
'\oi iCL CC
AOb\ )OcA oSgC'
Grantor(s): (1) L C_oX:10 z-n` , (2) h<J4-,/M. thv
Grantee(s): (1) PUBLIC
Legal Description (1) lQl ,
2 O? 5tAQ V �. 8/o .@ air&2a R4
�(A(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) a a o a E - `l 5 - O Q 0 / 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:
Maximum Annual Average Gallons Per Day: CIS() gallons
Dated on this day "
/ / of !�E t3 (4 , 20a-3 .
`�
Signature of Grantor(s):
(1) , (2)� 7"7
State of Washington )
County of,Maeaft i Q-Sr ci )
Page 1 of 2
A 41_ $'M
•
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this /q day of Fer324t , 20L3 ,
G401 L L dONNe- 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.
NOTARY PUBLIC
STATE OF WASHINGTON Notary Public in and for the State of Washington,
DELBERT P DETRAY //
COMM.#20102533 residing at /ffu�2 c rokr (?.19 u vr'1
COMM. EXP. 01/08/2024 My commission expires: /- - 267A
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