HomeMy WebLinkAboutWAT2023-00038 - WAT Application - 2/22/2023 ,;_ "xtti. WA -
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r MASON COUNTY
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COMMUNITY SERVICESFEB 2 2 2023
N. `4'7 Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584, 615 W. Alder Street
Shelton: (360)427-9670 ext 400 f• 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---)r79s Date: 2 - 22 • 23
Mailing Address: I 0 0 K 1111k i 1, - hone: 3LW• ---N(' 15'-I`1
Parcel Number: (p ( Z— Z/-00 U2 `5h, J . pi ,Q g858(---{
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more "Building permit DIcI 2023-60270
connections) ❑ Division of land:
Individual water source (one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
❑ Spring/surface water
CI (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:1E11 Forms\Drinking Water Revised 1/25/2018
Individual Water Well
yip Water well report(attached to application). Depth �C( ft.
O Well capacity Test (attached to application) 3 0 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) AF4/: Z i l t(o o
Development within which WRIA http://gis.co.mason.wa.us/planninq 15E1 16n 22 ]
Water use or limitation recorded N/A 0 Yes _
Well Drilled Date Il /f /13
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.
C Unsatisfactory Determination:
Applicant's water supply doArt-10,aioataaRciV a needs of its intended use for the following
•
reason(s). �
pitiffi2lenOignatures:
Environ. Health: lAAwU,`i Qw Y-ENVIRONMENTAL HEALT; Date 272 /72 3
DJA `°'
CSD Director: Date
• WVATER
IA MANAGEMENT
AIM LABORATORIES t
A1111111111 1615 50th St E,Tacoma,WA 98404
Mai .
NSW eOLIFORKPAPTERF4ANALYSISfORM
Dale Sample Collected Time Sample County
Collected
i2.Oi3
n :t3n?i2mpu
Ma* Day Yew
Type of Water System(check only one box)
0 Group A 0 Group B Other
Group A and Group B Systems-Provide from Wati Fadliges Inventory(WFI):
IDS
System Name: 61..n 0.1‘ •
Contact Persort Y44,2actick Brining, Inc
DRY Phone:(3V, 426-3395 Cell Phone:( ) •
Email: • -03 ... Eve.Phone:( )
Send results lo:fxi4full and zip code)
Argad. p0.1. , :4E-...86fAAe.., effiCtt 1 resoff5
()tP .,e..7.0 N..t-g-i.- -cLearcAtilstk,410(). C P.Wt
Shelton, WA 99594-
. . _
440:A.E-INPOR441iTION
Sample collected by(name):fyi
Specific location where sample col : Special instructions or comments:
itr
Jo tit K;11,sen L
140,0!**1.00.40PIYA949904.000-***14*911,0?*
1.0 Routine Distribution Sample(AfP) 2.0 Repeat Sample(NP)
Chionneled:Yes No Worn distribution system alter onset routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total__Free
• 3.Ground Water Rule Source Sample •
Unsatisfactory routine collect date:
Is I I
Chlorinated:Yes No
0 Triggered(A/P) Chlorine Residual:Total Free
0 Assessment(NP)
4.Surface or GWI Flaw Source Water Semple(Enumeration)
0 E.we 0 Fecal Famed Yak_ ISI I I
• 5. Sample Collected for Information Only:
LAB USE ONLY DRINKINq:W#0,§Aoucrs LAB USE
0 Unsatisfactory Total Coliforni Present and
0 E.coli present 0 E.00ll absent
Bacterial Density Results:Total Conlon ____J100rnl. E.con /100m1.
Focal Coliform /100ml. HPC /1 ml.
Replacement Sample Required: 0 TNTC 0 Semple too old
0 Sample Volume 0 Damaged Container 0
tterbRoZ. il7to thi't Lab ReferenberNum
Receipt Temp Mothad rfA
271e..gP
DaisReported to DOH Lab Use Only:AA0 0 4R
/-01 I --dc;- /4, _11 •
DON Lab-Samplet
I
089 ez-f-7
•
DOHA:ern/.331-31914x1h,MM. Au Nal tin putiaigcm tie itiMihWOMel CS11870.0.0117111Ast I rag 711).
•
WATER WELL REPORT 0...1171 DEPARI'MEN'I Ol Notice of Intent No WE51436
ECOLOGY Unique Ecology Well ID Tag No. BNV822
Type of Work State of Washington
l Construction Site Well Name(if more than one well):
❑ Decommission c-> Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: L+t Domestic 0 Industrial D Municipal Property Owner Name Gres Toms
0 Dewateritrg 0 Irrigation D Test Well 0 Other
Well Street Address 180 W Killion Creek Rd
Construction Type: Method:
O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other ❑Dug O Arr- ❑Mud-Rotary Tax Parcel No 62012-21-00020
Dimensions: Diameter of boring 6 in..to 99 ti.
• Was a variance approved for this well? 0 Yes O No
Depth of completed well 99 It.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To 'Thickness Steel PVC Welded Thread
Ca i 0 s in. 0 99 .025 in. E I ❑ 01 I 0 Location(see instructions on page 2): L W W M or O I W M
❑ 1 ❑ in. in. ❑ 1 0 0 1 0 SE Vs-1/4 of the NW 'h;Section 12 Township 20N Range 6W
❑ 1 ❑ —_in. — — in. 1 ❑ ❑ 1 ❑
0 Latitude(Example:47.12345) 47.239420 N
Longitude(Example:-120.12345) -123.381202 W
•
Perforations: 0 Yes DI No Type of petforator used
No.of perforations_ Size of perforations,in.by_in. Dritler's 1 og/Construction or Decommission Procedure
• Perforated from R.to ft.below ground surface Formation:Describe by color,character,size of material and stmente,and thekind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes El No 0 K-Packer Depth_ft information Use additional shears if necessary.
Manufacturer's Name __ Material From To
Type Model No.
Diameter_ Slot size_in.from _It to R. Brown fine sandy gravel,dry 0 4
Diameter Slot size is from ft.to R. Brown fine sandy gravel,slltbound,tight,dry 4 19
Sand/Filter pack:0 Yes 51 No Size of pack material_in. Brown fine to medium sandy gravel,tight,moist 19 25
Materials placed from R.to_.+ft. Brown clay,stiff,dry 25 36
Gray clay,stiff,dry _ 36 39
Surface Seal: el Yes ❑No To what depth? 19 ft. Brown clay,silty,tight,dry 39 46
Material used in seal Bentonite Chips ---
Did any strata contain umusabk water? 0 Yes CI No Brown fine sandy gravel,tight,wet 46 49
Type of water? Depth of strata Brown stiff clay,dry 49 58
Method of sealing strata off Brown fine sandy gravel,silty,light,dry 58 83
Brown coarse sandy gravel,tight,water 83 99
Pump: Manufacturer's Name Type: Brown siltbound gravel,dry 99
H.P. Pump Intake depth: ft. Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level 402 ft.
Stick-up of top of well casing 1 R above ground surface '-` -----'—
Static water level 22 R.below top of well casing Date 1/11/23
Artesian pressure lbs.per square inch Date__ --
Artesian water is controlled by (cap,valve,etc.)
—Well Tests:
Was a primping test performed? IN No 0 Yes c by whom?
Yield_gpm with_fi.drawdown alter_las.
Yield gent with—R.drawdown after hrs.
Yield gpm with R.drawdown rifler_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� 9.drawdown after hrs -
.Air test 30 gpm with stem set at 60 R.for 1 hrs. 1 Date 1/11/23
Artesian Bow gpm j �j
Temperature of water °F Was acheruical analysis made? 0 Yes 51 No Start Date 1/11/23 Completed Date 1/11/23
•
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
•
CI Driller D Trainee 0 PE- Print Name ay ythia Drilling Company Arcadia Drilling Inc. _
Signature Address PO Box 1790
License No. 2053 City,State,Zip Shelton,WA 98584 _
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 1/11/23
ECY 050-1-20(Rev 09/18) if you need this document in an alternate formal,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 ca11877-833.6341.
.
2194070 MASON CO WA
02/22/2023 01:11 PM NOTCE
TOMS *194464 Rae Fee: S204.50 Pa es 2
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MAR 2 3 2023
RECEIVED
Grantor(s): (1) g-IY/ 01(Y1 (2)
Grantee(s): (1) PUBLIC �.
Legal Description (1) 12 Sc nE S ) 1 / 2t O v
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) LP 20 12. -2- 1 - 0 00 20
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: off,
Maximum Annual Average Gallons Per Day: oev gallons
Dated on this 7?iv( day of /'ei)rLcct 9 , 20 Z. 3
Signature of Grantor(s):
(1) 1 z lC - � , (2)
State of W shington )
4 County of 44aseR
-1-1nu�?an
Page 1 of 2
I, the undersigned, a Not ry Public in and for the above named County and State, do hereby
certify that on this day of— ruco , 20 Z5 ,
person�y appeared before me, who known to be
signe f the above instrument, and acknowledged that he (she) (they)signed it.
GIVEN under my hand and official seal the day and year last above writt n.
-Gf/thi-v1 —44
c,stC/ , '1tt No a Public in and for the State of Washington,
.iso ''fAli'
o`M nr Nfs {f'i reading at UY'S1�l Vdt
�. �- m My commission expires: 6 -a-]- ek.1 1
-�S i ti �0770
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