HomeMy WebLinkAboutWAT2023-00028 - WAT Application - 1/23/2023 .�{: WATT
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,i l; • I?°) COMMUNITY SERVICES `" 25
'^yyl Building,Planning,Environmental Health,Community Health �A� 2 3 �
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415 N 6th Street, Bldg 8, Shelton WA 98584, �N A`der Street
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 Elma: (36g) 1F 2'5269 ext 400
FAX (360)427-7787
Application for Determination of Water Adequal-y Vi RO N MENTAL
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: GEOFF & KAREN SAUNDERS Date: 1I 9:12 f oDR7-,
Mailing Address: 12221 2ND AVE NW SEATTLE WA Phone: 206-383-9916
Parcel Number: 1 21 08-21-00070
Type of Water System Reason for Ap lication
❑ Public/Community Water System (2 or more 0 Building permit 0 Li)as�3—o0r 55
connections) ❑ Division of land:
O Individual water source (one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
❑ 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:`F.H Forms\Drinking Water Revised 1/25/2018
pia-
Individual Water Well
Water well report(attached to application). Depth 1S.-7) ft.
cy(- —....„
Well capacity Test(attached to application) LJ 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
(l by a licensed contractor.
6✓Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://dis.co.mason.wa.us/planninq 14 15n 16n 22n
Water use or limitation recorded N/A=Yes TYR
Well Drilled Date ?iJ)`'( 'Z3
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:
It 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: e. -)--ectS1/1r1 1 Date I-) ( LTh
'°t
CSD Director: Date
WATER WELL REPORT _ A.._. DEPARTMEN'I OF Notice of Intent No. WE51747
imi ECOLOGY Unique Ecology Well ID Tag No. BNV811
Type of Work: State of Washington
O Construction Site Well Namc(if more than one well):
❑ Decommission =-7' Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: IJ Domestic ❑Industrial 0 Municipal Property Owner Name Geoff Saunders
0 Dewatering ❑Irrigation 0 Test Well ❑Other
Well Street Address 4364 E Grapeview Loop Rd
Construction Type: Method:
New well ❑Alteration ❑Driven 0 Jetted ❑Cable loot City Grapeview County Mason
❑Deepening O Other ❑Dug III Air- El Mhid-Rotary Tax Parcel No. 121082100070
Dimensions: Diameter of boring 6 in.,to 158 fl
Was a variance approved for this well? 0 Yes No
Depth of completed well 158 ft.
Construction Details: WallIf yes,what was the variance for'?
Casing Liner Diameter Front To Thickness Steel PVC Welded Thread
OO I ❑ 6 in. 0 154 .025 in. R I 0 J I ❑ Location(see instructions on page 2): 15 WWM or O EWM
❑ 1 ❑ in. in. ❑ I ❑ ❑ I O NE %-'/,of the NW '/,;Section 8 Township 21N Range 1W
❑ 1 O in. _ in. ❑ 1 ❑ OID
❑ 1 ❑ tit. in. ❑ I 0 ❑ I ❑ Latitude(Example:47.12345) 47.327584
Longitude(Example:-120.I2345) -122.835244
Perforations: ❑Yes E No Type of perforator used
No.of perforations Size of perforations_in.by in. Driller's Log/Construction or Decommission Procedure
Perforated from_ft.to 8.below ground surface 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
Screens: El Ycs 0 No O K-Packer Depth 152 it information. Use additional sheets if necessary.
Manufacturer's Name-Alloy Machine Work Material From To
Type Stainless Slotted Model No.
Diameter 5" Slot size.012 in from 150 ft to 158 ft Brown silty sand and gravel 0 9
Diameter Slot size _in.front ft to 11 Brown medium sand,gravel 9 17
Brown silty sand and gravel 17 23
Sand/Filter pack:0 Yes O No Size of pack material in.
Materials placed Coin ft.to ft. Gray silty sand and gravel 23 31
Gray silt 31 57
Surface Seal: O Yes ❑No To what depth? 19 fi. Gray silty sand and gravel 57 78
Material used in seal Bentonite Chips
Did any strata contain unusable water? ElYes E No Brown fine sand,some gravel 78 81
Type of water? Depth of strata Gray silty sand,gravel,tight 81 97
Method ofsealing strata off Brown fine sand,gravel,wet 97 136
---- Brown fine sand,wood,peat,wet 136 140
Pump: Manufacturer's Name Type: Brown fine to medium sand,heaving,water 140 158
H.P. Pump intake depth: ft. Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level 30 It
Stick-up atop of well casing 1_5 II.above ground surface
Static water level 22 ft.below top of well casing Date 3/14/23
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? lJ No El Yes �::> by whom?
Yield gpm with ft.drawdown after firs -
Yield spin with It.drawdown alter hrs.
Yield gpm with_fl.drawdown after hrs.
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 It drawdown atter_hrs
Air test 50 gpm will:stein set at 120 fl.fur 1 hrs. - Dale 3/14/23
Artesian flow gpm _
Temperature of water 49 °F Was a chemical analysis made? ❑Yes O No Start Date 3/13/23 Completed Date 3/14/23
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.
E Driller 0 Trainee 0 PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc.
Signature 2 / 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 Date 3/14/23
ECY 050-I.20(Rev 09/I S) if you creed this document in an alternate frrrnrat.please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Sen•ice. Persons with a speech disability can call 877-833-634/.
• 1786 SE Mile Hill Drive
Port Orchard,WA 98366
SPECTRA Laboratories-Kitsap www,spectra-lab.com
—Mere aa,.rien.a.aa a» (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
3 1 24 23 ❑AM
12 00 Mason
Month Day Year
Type of Water System(check only one box)
❑Group A ❑Group B ['Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: Geoff Saunders
Contact Person:Arleta Eisele/Arcadia Drilling
Day Phone:360-426-3395 Cef Phone:
Email: arleta@arcadiadrilling.com Eve.Phone:
Send results to:(Print full name,address and rip code or e-mail)
arleta@arcadiadrilling.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Seth
Specific location where sample collected: Special instructions or comments:
#BNV811 COUNTS PLEASE
4364 E Grapeview Loop Rd,Grapeview
Type of Sample(check only one box)
1.❑Routine Distribution Sample 2.Repeat 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 Unsatisfactory routine collect date:
❑Triggered Chlorinated:Yes ElNo El
❑Assessment Chlorine Residual:Total Free
4. Enumeration Source Water Sample S I I
❑E.coli ['Fecal-Surface,G1N1,Springs.Fihered Yes❑ No El
5. Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
0 E.cok present ❑E.coif absent
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Coliform. �_ k p4100ml. 00m1.
Fecal Coliform /100m1. HPC 11 ml.
Lab ID Number Date o a Time eceived.
8D a/ Y/2-_. 3 [biz
Method Code. Date and Time Incubated*
SM 9223 B 3/2--(4 /2 4�
Date Analyze Jj /2 5 Date Reported'3/2,_. 2
DOH Lab-Sample# (�j/Y{� Lab Use Only:
.0lV/,alhDO, _
DOH Form e331.319(alMc.e 0016)-r. ipso''n n aWrneme lame(call 803525.0127(TOCei Y cA 71i)
The rid ogler putScallons are mailable at*Nor h n»a aaAa:traara'.
2195230 MASON CO WA
03/24/2023 :08 NO
SAUNDERS *18530182PM Roc FTCEee: $204. 50 Pages: 2
I!1 1hu 1�11�1 IhIi III III IMFrIIlIuHtl�HRI11111
Return To
(tee a // a•d 4/et') Sa i)/ de(s
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Grantor(s): (1) /741.<6/1 5;7-Un1.D6- S , (2) 6r; Oi-tc S190 D _R.S
Grantee(s): (1) PUBLIC 5 c7/.N 09
PCL 2 OF BLA#89-98 AF#501691 PTN OF GOVT LOT I &TAX 980' ►'`�ASH/ -2"
Legal Description (1) R A rkie c
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 1 2 1 0 8 _ 2 1 _ 0 0 0 7 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 /y _ day of Ml Aie CA/ , 20 2 3.
Signature of Grantor(s):
(1) �u2-An5 , (2) �� r c��•.-��
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public)Land and for the above named County and State, do hereby
mortify that on this I U day of , 20.)
()-e"C-r. <� arcl k(frcy 5c.,„r,J- P. 5 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�Pa ast above written.
.‘ NCHMii
O. fission' -/�►�% Notary Public in and for the State of Washington,
�2:oFo.2� zp�s;�•�� residing at ho'rc �i n C C hciS e
NoTAA). ' •11
=dr �►•� � = My commission expires: S- �` S
PUBLIC :=1
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