Loading...
HomeMy WebLinkAboutWAT2023-00063 - WAT Application - 3/20/2023 WAT 2.102 - A, \ MASON COUNTY RECEIVED' viii) COMMUNITY SERVICES Building,Planning.Environmental Heaith,Community Health MAR 2 0 2023 415 N 61h Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482-5269g110W. Alder Street 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'yt Vpt Date: A— 1 -20'). Mailing Address: 5 5?Q fj , no-44, Shoie ( Phone: ' Q 2- O6 Parcel Number: Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit DVt ZO2 3 0031 3 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL 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:EII Forms` l)iinkinn.Water Revised 1/25/2018 Individual Water Well Water 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. �l Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) aaa,,,��� Development within which WRIA http://gis.co.mason.wa.us/planninq 141 1 1 bl X 116(-1 22I j Water use or limitation recorded N/A 0 Yes jE:It Well Drilled Date -5/ v I 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) atisfactory 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'sw Signatures: Environ. Health: \Q"----TNYVI`� f l Date Vit I (Lt I 2°f2 CSD Director: Date WATER WELL REPORT -1 DEPARTMENT OF Notice of Intent No. WE45774 ECOLOGY Unique Ecology Well ID Tag No. BNX205 Type of Work: W State of Washington LI Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ❑O Domestic ❑Industrial ❑Municipal Property Owner Name Brenda Yates 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 5840 NE North Shore Rd Construction Type: Method: CityBelfalr County Mason M New well ❑Alteration CI Driven 0 Jetted 0 Cable Tool ❑Deepening ❑Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 22210-51-00906 Dimensions: Diameter of boring 6 in.,to 179 ft. Was a variance approved for this well? ❑Yes 0 No Depth of completed well 176 ft. If yes,what was the variance for? Construction Details: wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread IID 6 in. 0 179 0.25 in. g I ❑ O I 0 Location(see instructions on page 2): ©WWM or 0 EWM ❑ I ❑ in. in. El I ❑ 0 I 0 SE Y-1/4 of the NW '/.;Section 10 Township 22N Range 2W ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ ❑ I El in. - — in El I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.403121 Longitude(Example:-120.12345) -122.923698 Perforations: 0 Yes O No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations by— Formation: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: ❑Yes f l No ❑K-Packer e> Depth_ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To i Type Model No. Diameter Slot size in.from ft.to ft. Brown silty sand and gravel,cobbles 0 7 Diameter Slot size is from ft.to_ft. Brown silty sand and gravel,loose 7 20 Brown silt some gravel 20 24 Sand/Filter pacic 0 Yes (J No Size of pack material in Brown silty sand and gravel 24 34 Materials placed from ft.to ft. Brown medium sand 34 51 Surface Seal: El Ycs ❑No To what depth? 19 ft. Brown silt 51 53 Material used in seal Bentonite Chips Brown silty sand and gravel 53 92 Did any strata contain unusable water? ❑Yes O No Type of water? Depth of strata Brown medium sand 92 93 Method of sealing strata off Multicolored gravel,fine brown sand,silt 93 121 Brown silty sand and gravel with lenses of silt 121 137 Pump: Manufacturer's Name Type: Multicolored gravel,brown medium to coarse 137 H.P._ Pump intake depth:_ft. Designed flow rate:_gpm sand,water 139 Water Levels: Land-surface elevation above mean sea level 100 ft. Brown silty sand and gravel 139 142 Stick-up of top of well casing 1 ft.above ground surface Gray silty sand and gravel 142 147 Static water level 105 ft.below top of well casing Date 3/8/22 Gray clay with gravel 147 158 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Reddish brown silty sand some gravel,wet 158 162 Multicolored grave,fine brown sand,water 162 176 Well Tests: Multicolored gravel,fine brown sand,silt, 176 \Vas a pumping test performed? 2 No ❑Yes b by whom? loose,water 179 Yield gpm with_ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time=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 15 gpm with stem set at 160 ft.for 1 hrs. - Date 3/8/22 Artesian flow gpm Temperature of water 50 'F Was a chemical analysis made? ❑Yes O No Start Date 3/8/22 Completed Date 3/8/22 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 0 Trainee❑PE-Print Name o h Koepp Drilling Company Arcadia Drilling Inc. Signature /0/� Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License o. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 3/8/22 ECY 050-1-20(Rev 09/18) 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. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Brenda Yates Well Tag #: BNX205 Phone: 253-292-8006 Depth: 179' Well Site Address: 5840 NE North Shore Rd., Belfair Pump Set: 161' Date of Test: 3/16/2022 Static 102' TIME GPM LEVEL RECOVERY 1 Min 3.8 106.7 TIME LEVEL 2 Min 3.8 108.4 1 Min 138.9 3 Min 4.7 110.0 2 Min 123.7 4 Min 4.7 111.5 3 Min 119.3 5 Min 4.7 112.4 4 Min 116.3 6 Min 4.7 113.3 5 Min 115.7 7 Min 4.7 113.7 6 Min 118.9 8 Min 4.7 114.8 7 Min 118.9 9 Min 4.7 114.8 8 Min 118.8 10 Min 7.5 114.9 9Min 117.5 15 Min 7.5 121.0 10 Min 116.8 20 Min 13.0 123.0 25 Min 13.0 123.5 30 Min 13.0 133.9 35 Min 13.0 138.4 40 Min 13.0 140.1 45 Min 13.0 140.8 50 Min 13.0 141.0 55 Min 13.0 141.2 1 Hr 13.0 141.4 4 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com —Inresaowlene•/W«" (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 3 / 16 I 22 1 45 OAM Mason WO Day Yam ------•_ OM Type of Water System(chedt only one box) 0 Group A ❑Group B Qother Group A and Group B Systems-Provide from Water Far-lilies Inventory(WFl): ID* — — system Name: Brenda Yates 5840 NE North Shore Rd,Belfair Contact Person:Arleta Eisele/Arcadia Drilling Day Phone: 380-426-3395 • [Cell Phone: Email: arleta@arcadiadriling.com Eve.Phone: Send results to:(Print tut name,address end zip code or e-mail) a rieta@arcadiadrIllIng.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Seth Specific location where sample collected: Special instructions or comments: Well Head *BNX205 Type of Sample(check only one box) 1.0 Rouline Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes❑ No❑ 0 Distribution System Chlorine Residual:Total_Free Unsatisfactory routine lab number: -, 3.Source Ground Water Rule Sample .__— ___ ———— S l I Unsatisfactory routine collect date: _J I ❑Triggered Chlorinated:Yes❑ No❑ Chlorine Residual:Total_.__ Free_ ❑Assessment 4. Enumeration Source Water Sample S I 0 E.coil ['Fecal- ow.eprtuge Flhered Yea No El ` L 5.Q Same C.:00 d for Information Orly: LAB USE ONLY DRINKING WATER RESULTS ITUSE ONLY ❑Unsatisfactory Total Coliform Present and atis factory I ❑E cull present ❑E.coll absent I Replacement Sample Required: -, I 0 Sample too old(>30 hours) 0 TNTC 0._ Bacterial Density Results:Total Cotiiorm. ... 1100m1. E.coli 1100mi. Fecal Cdiform___- /100m1. HPC__ ._ __it ml. ��r Lab 10 Number Date and Time Received: Tr,11) l 'L'YOLI 'O L. MAR 17 2022 106 G Method Cede: late and Time Incubated: SM 9223 B MAR 17 2022 Dale Analyzed. Dale Re fitAti 1 8 n72 ----MA(- 8 7n22 - DOH LatSamyl Lab use Orly: 225 - LQ L fkira.i-mi4T9NlforMV/14•n ya need Ms plaiNG'na'I66mM kelt,cell Val 52SC127 RY1Ti cal 7r Th,and abr pxlaS:i»an are a&Y rxa lRve kMyy,vy,aY, 2194845 MASON CO WA 03/15/2023 09:51 AM NOTCE BRENDA YATES #185070 Rao Fee: $204.60 Pages: 2 Return To II III!I II i 1111111111111I11i 1111111111 n11111 I11111II 1111 ec .n v i1t 00,At\ C(VC,2 tom' Grantor(s): (1) €?1 e),i\OV`). / , (2) Grantee(s): (1) PUBLIC Legal Description (1)Om.,2 r16-tLr ns 5uvrtui 1510ni'Q.P be i'le17 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) oC oZ a+ I 6 - 5 I - D O I S \� —T 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: 9 1c.) gallons Dated on this ( 5 day of n..0 , 20 . Signature of Grantor(s • (1) .2/ • !� (2) 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 ce i hatonthis i5t." day of , 20 ' , 13:"e..v1drA ya-R. 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 year last abovawritten. v Notary Public if CPC. '1' State of Washington ARIANE M PAYSSE Notary Public in and' or �� a/State� off Washington,/ MY COMMISSION EXPIRES residing at i 0-4-tr Y\ l�(1 ittA4 12/29/2025 i/ My commission expires: I )F z Page 2 of 2