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HomeMy WebLinkAboutWAT2023-00074 - WAT Application - 4/18/2023 • • ,�„�, �. MASON COUNTY 1WAT2 - 0OO 2�j COMMUNITY DEVELOPMENT RECEIVED Permit Assistance Center,Building,Planning 415 N 6'h Street, Bldg 8, Shelton WA 98584, APR 18 2023 Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 •:• Elma: (360)432,� 6t9„ext 400 Street FAX(360)427-7787 VVV Application for Determination of Water Adequacy ' i 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: Luke & Mandy Manning Date: Mailing Address: 3300 21 st Ave SW Apt H8, TumwPhone: 360-490-0068 Parcel Number: 42125-11-50030 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ❑ Building permit—i)Id 202-3- 004 ION connections) 0 Division of land: 0 Individual water source (one connection), #of Parcels? SPL O Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ 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 125 2018 Individual Water Well O Water well report (attached to application). Depth 189 ft. 0 Well capacity Test(attached to application) 20 gpm Not given 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. O Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) // Development within which WRIA http://qis.co.mason.wa.us/planninq 14LA"150 16U 22= Water use or limitation recorded N/A 0 Yes EV Well Drilled Date \--14Z C v I L7 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: 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: Ajy ‘11/( -) 7Environ. Health: Date c 3 2°t CSD Director: Date WATER WELL REPORT ,,,,, a DEPARTMENT OF Notice of Intent No. WE50216 alma ECOLOGY Unique Ecology Well ID Tag No. BNV825 Type of Work: illailli State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission ---. Original installation NOI No. Water Right Permit/Certificate No Proposed Use: III Domestic 0 Industrial ❑Municipal Property Owner Name Amanda Mannino ❑Dewatering 0 Irrigation ❑Test Well CI Other Well Street Address Pacific Ridge Road Construction Type: Method: E Ncw well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 421251150030 Dimensions: Diameter of borin6 in., 189 ft. to Was a variance approved for this well? 0 Yes 0 No Construction Depth Details:ofcompleted well 189 Wall ft. If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I ❑ 8 in. 0 185 .025 in. O ❑ E I ❑ Location(see instructions on page 2): [8 WWM or❑ EWM ❑ I ❑ in. _ _ in. ❑ I ❑ ❑ I ❑ NE '/.-'V.ofthe NE '/.;Section 25 Township 21N Range 4W ❑ I ❑ in in. ❑ I ❑ ❑ I ❑ O I ❑ in _ _ in ❑ I ❑ 0 I El Latitude(Example:47.12345) 47.284330 N Longitude(Example:-120.12345) -123.124545 W Perforations: 0 Yes O No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft.to fl.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes ❑No O K-Packer r '- Depth 183 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5" Slot size.020 in.from 184 fi to 189 ft. Medium to coarse sandy gravel,clean,dry 0 15 Diameter Slot size_in.from ft.to ft. Brown medium sandy gravel,silt bound, 15 tight,dry 27 Sand/Filter pack:❑Yes O No Size of pack material in. Brown medium sandy gravel,tight,wet 27 59 Materials placed from ft.to ft. Brown gravelly fine to medium sand,heaving 59 87 Surface Seal: E Yes 0 No To what depth' 20 It. Brown fine sandy gravel,silt bound,dry 87 96 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes E No Gray silty clay,stiff,dry 96 111 Type of water" Depth of strata Gray clay,hard,dry 111 132 Method of sealing strata off Black sharp gravel,gray silt binding,tight,dry 132 139 Brown medium sandy gravel,sharp,tight, 139 Pump: Manufacturer's Name Type: dry,silty 152 H.P. Pump intake depth:_ft. Designed flow rate. gpm Brown medium sandy gravel,tight,wet 152 179 Water Levels: Land-surface elevation above mean sea level 291 ft Loose coarse brown sandy gravel,water 179 189 Stick-up of top of well casing 1 ft.above ground surface Gray silty clay,dry 189 189 Static water level 142 ft.below top of well casing Date 12/28/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No ❑Yes by whom? 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 20 gpm with stem set at 180 ft.for 1 hrs. - Date 12/28/22 Artesian flow gpm _ Temperature of water 51 °F Was a chemical analysis made? 0 Yes E No Start Date 12/28/22 Completed Date 12/28/22 WELL CONSTRUCTION CERTIFICATION: 1 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 18)Driller 0 Trainee 0 PE—Print Name o ray Phythian 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 12/28/22 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Fragrant 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. 1786 SE Mile Hill Drive Port Orchard,WA 98366 )1, SPECTRA Laboratories-Kitsap www.spectra-lab.com =.,truce,r0,a.nce manors (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM __ Date Sample Collected Time Sample County Collected 1 / 9 / 23 2 00 ❑nM Mason ?Acne, Day 'fox - ---mom Type of Water System(check only one box) 0 Group A 0 Group B I]Other Group A and Group B Systems-Provide from Water Faclittes Inventory(WFI): ID# System Name:Amanda&Luke Manning Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-426-3395 Cell Phone: Email: arletaf©arcadiadrIlling.com Eve.Phone: Send results to:(Print fug name,address and dP Cade or s malf) arleta@arcadladrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Seth Specific location where sample collected: Special Instructions or comments: BNV825 Pacific Ridge Rd,Shelton Type of Sample(check only one box) 1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ ❑Dlstribulion System Chlorine Residual:Total___Free_ Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample ISI I I Unsatisfactory routine collect date: ❑Triggered Chlorinated:Yes ElNo El ❑Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample I I I ❑E.coil ❑Fecal.Sulam,ov,Springs Flnm.d ya❑ NOD 5.0 Sampla Corected fer Intormauon 0n:y: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Califon Present and ‘'" Isfactory 0 E.coli present ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Cotiform __/100m1. E.coli /1C0ml. Fecal Coliform 1100ml. HPC _l1 ml. Lab ID Nu�ber`p CoTv Data and Time Received: iZ C ^0) JAN 10 2023 R13 Method Code. Date and Tlrne Incubated SM 9223 B JAN 10 2013 Cate Analyzed: JAN 1AN 1 1 N21 DateReperlejAN2023 1 1 COH Lab-Samcir Lac Use Only: 225 ._ ) _. ccvromi/mlmn ptec)ya na,driap.erniona and,amiMIorn,l eal NO ilidrf7 UTOOTt(churl} — 1,1s and di,paldatM>o o lrab,N dontdoNws.pedtrlreavdaUr. • 2196064 MASON CO WA 04/19/2023 09:25 AM NOTCE _ 1111Carlifq IIIIII 19 IIIII IMI IIIII I IIIII III I IIII� 2 Return To .33 cV Pwe �« Grantor(s): (1) SIVr•icl-A N1 CIA V\,nQ , (2) L.v- c �0.nr1 nC, Grantee(s): (1) PUBLIC J Legal Description (1) LA'3 of LL..54-bL' -OZ ri of f `jy 6 33J229 ' 230 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) '-I Z . 1 2_ S - 1 1 - 5 0 O 3 0 Si a 1 try TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) l (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: 1`t Maximum Annual Average Gallons Per Day: 9t5Q gallons Dated on this day of ADYL_L- , 20 Signature of Grantor(s): /' (1) � (2) State of Washington ) County of Mason Page 1 of 2 0 A I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 1 Jay of al)►f t. 1 , 202_ c{- 1 personally appeared before me, who is known to be signer of the above instrument, an acknowledged that he(she) (they) signed it. GIVEN under my hand and official seal the day and year last above written JOIWaaa-er Notary Public in and for the State of�� Waon, TERESA L WAY Notary Public residing at ill L.IJf L i'i..(7..,, 4 State of Washington License Number 135501 My Commission Expires My commission expires: 05/ 112 l May 15, 20244 j • • Page 2 of 2