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Home My WebLink AboutWAT2022-00278 - WAT Application - 7/11/2022 /� •r�,�tk^ WAT la?, - G�bz1S y 7 MASON COUNTY 'x' COMMUNITY SERVICES �— .r .4., ,,,c, Building,Planning,Environmental Health,Community Health 415 N 6tr,Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400 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: C.4.-f t S s M EL 11 A-USYlitle: 7/IJ I ZZ- Mailing Address: 3 20 F i Sp I2b Phone: 34,6 --fr/ , 9s&D I Parcel Number: ZZ o r-7 -"l 5 - 0 0 3-7 (0 4 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more El- Building permit '?))G1 2022. -DID3`-t connections) 0 Division of land: II, Individual water source (one connection), #of Parcels? SPL 65- Well 0 Boundary line adjustment 0 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 1/25/2018 Individual Water Well -R Water well report(attached to application). Depth 1 So ft. ifK Well capacity Test(attached to application) 2D 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/planning 14 (15rJ 1 bl 1221—J Water use or limitation recorded N/A=Yes Ocf Well Drilled Date � t ( ' Ca 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: COAcl Date •'( 9;1,2Z" 2°e2 CSD Director: Date , i WATER WELL REPORT DEPARTMENT 0" Notice of Intent No. W359591 ECOLOGY Unique Type of Work: • State of Washington Ecology Well ID Tag No. BJT932 x Construction Site Well Name(if more than one well): ❑ Decommission ,---> Original installation NOI No. Proposed Use: x Domestic 0 Industrial 0 Municipal Water Right Perrnit/Certifieate No. 0 Dewatering ❑Irrigation ❑Test Well ❑Other Property Owner Name Chris Auseth Conatractbtt Type: Method: Well Street Address Between 110 and 370 Day Springs Road x New well 0 Alteration 0 Driver 0.lotted x Cable Tool City Shelton County_ Mason ❑Deepening 0 Other _ 0 Dug 0 Air- ❑Mad-Rotary Tax Parcel No. a 01 7 y < 5_ ?Do c9,60 Dimensions: Diameter of boring 6 ha,to 180 ft. Depth of completed well 186 ft. Was a variance approved for this well? ❑Yes X No Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread X I a in. ±1 1 5 .250 in. x 1 0 it 1 0 CI I ❑ in. _ in. 0 I 0 0 I 0 Location(see instructions on Page 2): x WWM or❑EWM ❑ 1 ❑ to in. ❑ 1 ❑ ❑ 1 ❑ Nw' -'A of the se''4;Section jl Township an Range 2w ❑ 1 ❑ in in. ❑ { ❑ ❑ ( ❑ Latitude(Example:47.12345) Lonitude Perforations: 0 Yes x No Type of perforator t sod (Example:-120.12345) No.of perforations Size of perforations, in.by in. Driller's Log/Conatrucdon or Decommission Procedure Perforated from ft.to ft.below ground,unto- Fotmation:Describe by color,character,size of material and structure,and the kind and Screens: x Yes 0 No nature of the material in each layer penetrated,with at least one entry for each change of x K-Packer C Depth i7 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson __ — Type Stainless wire wrap Model No. Material From To Diameter 5 Slot size i2Q in,from 1�75 ft.to 1A2 ft Brown Top soil— — 0 1 Diameter Slot size in.from ft.to ft. Brown Sand 1 14 Sand/Filter pack Yes X No Size of pack materiai in, Brown S ty day 14 19 Materials placed from ft to @ Brown Blue clay with silty sand 19 35 Surface Seal: x Yes 0 No To whatdepth?MIL sandWater 35 43 Material used in seal bentonite chips Gray clay with peat,wet 43 160 Did any strata contain unusable water? ❑Yes x No Black sand&gravel,Water 160 180 Type of water? Depth of strata Method of sealing strata off i Pump: Manufacturer's Name Franklin j I Type:Submersible _ H.P.2 Pump intake depth122 fti Designed flow rate:aQ gpm Water Levels: Land-surface elevation abalse mean sea level ft. Stick-up of top of well casing+1 ft.above ground surface Static water level 143.5 ft.below top of wall casing Date 10/11/18 Artesian pressure lbs.per square in Date Artesian water is controlled by_(qq1,valve,etc.) r Well Testa: i Was a pumping test performed? x No Yee by whom? Yield gpm with_ft.drawdowf after hrs. Yield gpm with_ft.drawdown after , hrs. Yield gam with ft.drawdown after b s. Recovery data(time-zero when pump is turned off-water level measured from well top to water level) t 1 Time Water Level Time Wain Lail Time Water Level 1 — i— Date of pumping test Bailer test 20 gpm with ft.drawdowe!eri im. l Air test gpm with stem set at i<I for ' ars. r Date 10-11-18 Artesian flow gpm Temperature of water °F Was a chemical analyse made? 0 Yes x No Start Date 9-24-18 Completed Date 10-11-18 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for oonstruction of this well,and its oompliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. X Driller Li Trainee LJ YE-Print Name LHvane Kr app Drilling Company Knapp Drilling Inc Signature '..-0{,,,,e,,. (ra...fp Address 50 E Lesaca Drive • License No.1706 City,State,Zip Shelton,Wash 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor',SignatureRegistration No.KNAPPDI952B1 Date 10- 17-18 ECY 050-1-20(Rev 09/18) Ifou geed this document in an alternate formal,please call the Water Resources Program at 3 60-4 0 7-68 72. Persons with heor ing loss car call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. rrir r i Thurston County Environmental Health • .,: 2000 Lakeridge Dr.SW !Olympia,WA 98502 1,.. THUR 360 867-2631 mumfforrimum COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample i County Collected . / - o AN__OPM rdonth Dey Year Type of Wafer System(check only one box) 0 Private Household ❑Group A ❑Group B ❑Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# ---- System Name: Contact Person: Day Phone:( ) Cell Phone:( ) E-mail: • Eve.Phone:( 1 Send resks to:(Pant full name.address and zip code or email address) Li_ SAMPLE INFDRMATION — i • Sample collected by(name): Specific location or address where sample collected: i Special instructions or comments: ii • Type of Sample(must check only one box of#1 through#4 listed below) 1 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total Free _ Chlorinated:Yes No • 3.Raw Water Source Sample Chlorine Residual:Total Free_ ❑E.coil-GWR(A!P) 0 Fecal-Surface.owl.spmgs inerremionl Unsatisfactory routine lab number: • Filtered:Yes__-_.No__ __ __-_ —.- — -- --- ❑Assessment Monitoring(A!P) Unsatisfactory routine collect date: I ❑Other i —_l S 4.1]Sample Collected for Information Only Investigative Construction 1 Repairs Other j LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Colifonn Present and 0 SatisfactoryNo Colilorm detected 0 Etapresent 0 E.coli absent Replacement Sample Required: 0 Sample too old(>30 hours) 0 TNTC 0.--_ Bacterial Density Results:Total Coliform_. 100m1. E.coli_____;100m1. Fecal Coliform__It00ml Enter000cc_ ----l100 ml. Method Code:0 SM 92236 ❑SM 9222D Date and Time Received: ❑SM 9215B ❑Enterolertt Analyzed: Date Reported: Date and Time Lab Use Only: Sample Number(DOH number pks five digits) 0 8 0 `— DOH Form 4331.319(revised 01116) t • 2188816 MASON CO WA 10/04/2022 02 35 PM NOTCE AUSETN 4 +�� s I' ' I1aI11180451 1111m Return To tptio 5 he, frnt. WA b5si-i Grantor(s): (1) -44-1?t S AvS�t� , (2) Grantee(s): (1) PUBLIC S(1AT2-DR2— Legal Description (1)?CA- I of NA t lE,•3,9, AF4 .2.IO:11`4 ?In oI51/2. 61.1) n3 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) ? 0 I 1 - 5 .- 0 U O 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: I Ll Maximum Annual Average Gallons Per Day: 1 6 gallons Dated on this `T day of , 202-i- Signature of Grantor(s): (1) / pt/c5-(3iL (2) State Washington ) County of Mason Page 1 of 2 I I, the undersigned, a Notary Public in and for the above named County and State, do hereby certjty that on this day of OCiobe i - , 2012 , r+'S A1.4 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 a'd year last above written. Notary Public v� / , 1r�VW)° State of Washington Notary Public in an. Air the State of Washington, ARIANE M PAYSSE In ��,O��I MY COMMISSION EXPIRES residing at /14 12/29/2025 My commission expires: i2r a 2O Z5 Page 2 of 2