HomeMy WebLinkAboutWAT2023-00062 - WAT Application - 3/16/2023 - WAT 2c;2V2 — 00060A
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MASON COUNTY
COMMUNITY SERVICES
11/4.„ . 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 •A 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: '(11,()j n V)116 LA))L ? Date: \ —I lP- g
Mailing Address: C E A p pa]oo'2A v6�Phone: 3LV n 9.o I 01 1 (C
Parcel Number: ).2 2C 1 — 1 if- GOOS0 3 Shpl;;1-0 __
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit 1 id 2023 . 06361
connections) ❑ Division of land:
XIndivid al water source (one connection), #of Parcels? SPL
Well ❑ 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)
0 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.
0 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.
Forms\Drinking Water Revised 1/25/2018
Individual Water Well
XWater well report (attached to application). Depth ` 1 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/plannincl 14d1150 16=221-7
Water use or limitation recorded N/A YesnSel
Well Drilled Date \\'2-77'Z Z
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: V----C-Thf\Q.Y"\A)c)S‘MlDate 1(L t L
2
"l,
CSD Director: Date
WATER WELL REPORT . . DEPARTMENT Of Notice of Intent No. WE50758
r,_ ECOLOGY Unique Ecology Well lU Tag No. BNV831
Type of Work: Stale of Washington
CI Construction Site Well Name(if more than one‘sell):
0 Decommission Original installation NOI No. \Paler Right Permit/Certificate No.
Proposed Use: CI Domestic Cl Industrial ❑Sfunicipal Property Owner Name Edwin Knowles
0 Dewatenng ❑Irrigation 0 Test Well 0 Other
Well Street Address 300 E Appaloosa Drive
Construction Type: Method:
K1 New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
, ❑Deepening ❑Other 0 Dug li)Air- ❑Mud-Rotary Tax Parcel No. 22001-76-00080
Dimensions: Diameter of boring 6 in,ro 127 ft. Was a variance approved for this well? 0 Yes E No
Depth ofcornpleted well 127 n
Construction Details: Wall If yes,whatwas the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
CS 1 0 6 in. 0 120 .025 in. [I I 0 ii I D Location(see instructions on page 2): 0 WWM or 0 EWM
D I Q in. in. ❑ I ❑ ❑ I ❑ SW V.-Y,of the SW Y,;Section 1 Tosasship 20N Range 2W
D I ❑ in. in. D I ❑ El I El
• I ❑ in. in. D I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.244201 N
Longitude(Example:-120.12345) -122.880481 w
Perforations: ❑Yes al No Type olperforator used
y No.of perforations_ Sim ofperCoralions in by in.
Driller'%Log/Conslruclion or Decommission Procedure
LPerforated from ft.to R.below ground surface Perforated Describe by color,character,size of materialaril slr xlure,and the kind and
_ nature of the material in each layer penetrated,with at least one entry for each change of
3 Screens: GJ Yes 0 No GI K-Packer r- --> Depth 118 n information Use additional sheets if necessary.
as Manufacnuer's Name Alloy Machine Works Material From To
c Type Wire Wrapped blodel No.
Diameter 5- Slot size.020 in.from 119 ft.to 124 n. Brown gravelly medium sand,silty,tight,dry 0 44
5 Diameter Slot size in.from ft.to n. Brown medium clean sand,loose,dry 44 90
Brown clay,hard,dry 90 91
`o Sand/Filter pack:0 Yes C7 No Size of pack material in Brown gravelly medium sand,loose,wet 91 101
Materials placed from R.to ft.
Brown fine sandy sill,wet 101 112
oSurface Seal: IC Ycs 0 No To what depth? 19 R. Brown gravelly fine to medium sand,wet active 112 125
Material used in seal Bentonite Chips _
Did any strata contain unusable water? 0 Yes El No Black gravelly gray clay,hard,dry 125 127
L Type of water? Depth of strata
O Method of sealing strata off
O Pump: Manufacturer's Name - -- Type:
— 1 LP, Pump intake depth:—ft. Designed flow rate: gpns — --
a
3 Water Levels: Land-surface elevation above mean sea level 189 ft.
v Stick-up of lop of well casing 1.4 ft.above ground surfaee
— Static water level 8s ft.below top of well casing Rite 11/23/22
>* Artesian pressure lbs.per square inch Date
Artesian%cater is controlled by (cap,valve,etc)
LE Well'feses: --Was a pumping test performed? Cl No 0 Ycs c= by whom?
Yield gpm with ft.drawdossn after hrs. -- ---
Yield —gpm with_R.drawdossn aver_hrs. _ ....A ----
Yield pent with R.drawdossn after its. , ' ,
in Recovery data(time=zero when pump is turned off—water level measured from well
Da top to water level) AN
AA 7 �) �]
Time Water Level Time Water Level Time \\'arml. set ------ --- AN t LJ23
—
Date of pumping test i s
o Bailer test—gpm with_ft.drawdossn after hrs
Air test 15 gpm with stem set at 105 ft.for 1 hrs. Date 11/23/22
y Artesian now gpm
E Temperature of water 52 °F Was a chemical analysis made? 0 Yes fl No
Start Date 11/22/22 Completed Date 11/23/22
L
WELL CONSTitUCt'ION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
3 construction standards.Materials used and the information reported above are true to my best knowledge and belief.
cuto J Driller 0 Trainee 0 PE—Print Nam Pra P Drilling Company Arcadia Drilling Inc.
_Signature Address PO Box 1790
License No. 2053 City,State,Zip Shelton,WA 985134
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 11/23/22
ECY 050-1-20(Rev 09/18) If you need this document in an alienate format,please call the leader Resources Program at 360-407-6S72.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-S33-6341.
Thurston County Environmental Health
2000 Lakeridge Dr.SW it Olympia,WA 98502
360 867-2631
TFIURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected O AM
07 30 0 PM !mot K:;:.1
Month Day Year
Type of Water System(check only one box) El Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: 6Cdwrn 5
Day Phone:( ) Cell Phone:( 34-e )301 x7/Li
E-mail: fi-hei(< s«gn 61•0gs;n+(.ion, Eve.Phone:( )
Send results to:(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name):
�l.,r,vr�. l t'4 uw l'f
Specific location or address where sample collected: Special instructions or comments:
'300 E. Apilvslr,.,,•, Pr.
Type of Sample(must check only one box of#1 through#4 listed below)
1.,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(NP)
❑Fecal-Surface.Owl,sprays(numeratbnl Unsatisfactory routine lab number:
Filtered:Yes No___
❑Assessment Monitoring(AR) Unsatisfactory routine collect date:
❑Other /
S I 4.0 Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent No liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC 0
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code:J,SM 9223E OSM 9222D Date and Time Received:lt-
❑SM 9215B ❑Enterolert t k 2-5-ZZ 1'2.-I S
Date and Time Analyzed: 12-5•ZZ Date Reported12 (e ZZ
Sample Number(DOH number plus eve ts) Lab Use Ordy:
0 8 0 c:uscnl,r>_c,/
cA
DOH Form 0331.319(revised 01116) --7
(m7.11" (�loweS �OtZ6 /Q
2194626 MASON CO WA
03/08/2023 09:30 Aft NOTCE
EDWIN KNOWLES #184888 Rec Fee: $204.50 Pages: 2
Return To. 111111111 II 1111111 III IIIIII III Ill IIII 111111111111 II ill II!ll 111111
_LiILv1✓I1600 (L'2
‘4t;D G , ppc�-loo6-' 1)r2 .
5 het im. Ld A g1;c)l--E
Grantor(s): (1) Mr'
WI l'1 Y1nt L) IU1 , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) 6L)(V-1 7/ '1 . - 1- CJ
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 3 0 0 I - 7 (o - 0 0 0 ? (7
So I - T2o -R2
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
Maximum Annual Average Gallons Per Day: gallons
Dated on this 6 day of , 20 23 .
Signature of Grantor(s):
(1) , (2)
State of Washington
County of Mason )
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I
A
•
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this r day of 0'OXL 1 , 20 2 ,
Ec\kL C 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
mammal‘) 41(Ott Y\k-'Pa
State of Washington Notary Public in'and^ for t �,S\tate of Washington,
MY COMMISSION EXPIRES residing at 14?Gv�C� r W L� r
12/29/2025 My commission expires: I /ZqJ2S
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