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HomeMy WebLinkAboutWAT2023-00070 - WAT Application - 4/12/2023 WAT 20?� - 000/0 0v` ,,,;•rf.tyt,,,r:. MASON COUNTY ill" FJ COMMUNITY SERVICES K E C�. I D f T .- `zY`� Building,Planning,Environmental Health,Community Health APR 1 2 J23) 415 N 61h Street, Bldg 8, Shelton WA 98584, pier Street Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)48g51�Wi 46 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: k(, ,v (,`), " <v Date: fkec,k )0 t Zl?23 Mailing Address: 1, SOx :7 2., F 2ood 'AilitciS'S tbne: ??,0 ' ,ct Cir.7 1 Parcel Number: 220_S(-) - y 2. - 9 0 0 i Type of Water System Reason for Application ❑ Public/Community Water System (2 or more L9' Building permit - jid 2o23 -CO nnections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL 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) 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. ❑ 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 r Individual Water Well Water well report (attached to application). Depth 12' ft. cq& Well capacity Test (attached to application) 3 C : gpm 360 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://qis.co.mason.wa.us/planninq 141 .151 116n 22= Water use or limitation recorded N/Aj Yes cZ Well Drilled Date .3 I k - a L 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: \�'--�1 `w4LIV17-1 Date 1 j IZ 5 `°r2 CSD Director: Date • WATER WELL REPORT 5r_,] DEPARTMENT OF Notice of Intent No. WE47601 ECOLOGY Type of Work State of Washington Unique Ecology Well ID Tag No. BNX207 O Construction Site Well Name(if more than one well): 0 Decommission r=> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: I]Domestic 0 Industrial 0 Municipal property Owner Name Barney Bruff 0 Dcwatering 0 Irrigation ❑Test Well 0 Other Well Street Address 5632 SE Arcadia Rd Construction Type: Method: !9 New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug ©Air- 0 Mud-Rotary Tax Parcel No. 22030-42-90012 Dimensions: Diameter of boring 6 in.,to 174 ft. Depth of completed well 172 Was a variance approved for this well? El Yes E No Constriction Details: wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O 1 ❑ 6 in. 0 170 .025 in. a I 0 0 I 0 Location(see instructions on page 2): ©WWM or❑EWM ❑ I ❑ in. in. ❑ I ❑ ❑ 1 ❑ NW 1/4-/of the SW %;Section 30 Township 20N Range 2W ❑ 1 ❑ in. _ in. ❑ I ❑ DID ❑ I 0 in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.192432 Longitude(Example:-120.12345) -122.979919 Perforations: ❑Yes NI No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated from ft to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: lia Yes 0 No RI K-Packer b Depth 166 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless Slotted Model No. Diameter 5" Slot size.020 in_from 167 ft to 172 ft. Brown silty loam 0 5 Diameter Slot size in.from ft.to ft. Brown silty sand and gravel 5 20 Brown medium sand 20 29 Sand/Filter pack 0 Yes l No Size of pack material in. Materials placed from ft.to ft. Gray silt 29 38 Surface Seal: ElYes 0 No To what depth? 20 Il Brown silty fine sand,wet 38 52 Material used in seal Bentonite Chips Brown silt 52 59 Did any strata contain unusable water? ❑Yes t J No Gray sand clay 59 64 Type of water? Depth of strata Gray silty sand and gravel 64 111 Method of scaling strata off Black gravel,fine gray sand 111 119 Gray fine silty sand,some gravel 119 133 Pump: Manufacturer's Name Type: Black gravel,medium black sand,loose 133 152 H.P._ Pump intake depth: ft. Designed flow rate: gpm Black medium to large gravel,medium 152 Water Levels: Land-surface elevation above mean sea level 100 ft. black sand,water 172 Stick-up of top of well casing 1 ft.above ground surface Black silty sand and gravel,wet 172 174 Static water level 101 ft.below top of well casing Date 3/11/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) _._ Well Tests: Was a pumping test performed? C No 0 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 R drawdown after hrs. Air test 30 gpm with stem set at 160 ft.for 1 hrs. - Date 3/11/22 Artesian flow gpm _ Temperature of water 49 °F Was a chemical analysis made? 0 Yes CI No Start Date 3/10/22 Completed Date 3/11/22 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. E Driller 0 Trainee 0 PE—Print N e Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 //frs"-° City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 3/11/22 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. • • l Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste. C ...Where experience matters Poulsbo,WA 98370 Phone: (360)779-5141 www.spectra-lab.com Spectra Labs - Kitsap,LLC (Poulsbo) received samples for Barney Bruff on Friday,April 14, 2023 at 4:40 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 225996-01 Private Well 5632 SE Arcadia Rd 04/14/2023 6:55 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.spectra-lab.com. This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 04/18/2023 Page 1 of 1 h • SPECTRA Laboratories- Kitsap .„tahe a experience:waiters ' COLIFORM BACTERIA ANALYSIS:FORM_ 1" Date Sample Collected Time Sample County Collected /� _ , ^'� '�y ' 23 s5 b6 Mason daoa — / o y�5 Type of Water System(check only one box) p.�,]�no C� ❑Group A ❑Group B . �Other l r Ae Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Persoc:Wandj Milrep- 13.0,rney $!''FC, t Day Phone:(360)877-5249 J Coil rhene�( )49 Send results to:print full name,edema and lip code or email shove tor electronic CO of raMg) brandyneameearpudl.ay _ 'ga.rney 1P T f%J '6t„bru fr3ooet,ofr+,,Lco- to 13ox 272. xds�+ ►�R 9Js4 SAMPLE INFORMATION.;; "•'_. 5s. Sample collected by(name): ,e7 9 _V C p Specific location where sample collected: t�C Specialel instructions or comments: 56.32 Sj• Att 4t; Ne,,.) we..0 Type of Sample(check only one box) 1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(AlP) Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: SI I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment(AIP) 4.Surface or GWI Raw Source Water Semple(Enumeration) ` S ElE.coil ❑Fecal Flmrad Yes_No 5.I Sample Collected for Information Only. LAB USE ONLY DRINKING WATER.RESJJLTS=' -LAB USA ONLY ❑Unsatisfactory Total Coliform Present and satisfactory ❑E.colpresent ❑E.coli absent Bacterial Density Results:Total Coliform pn/100m1.E.coli mpn/100m1. Fecal Coliform cfu/100m1. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container 0 APR /lam/O Lab Reference Sbe 'c —a/ . Receipt Temp C': Method Code: SM92238/QT•COUNT/SM92220 m Date Re n d ereport is owed s01MyIcebe we et en person 4 b coppery Morn rt a e#eseea Am en.aopyanp or dadan ether ten byte 1/ CI 3— denied recipient le waudbr¢ed.If you have received die expo-tin rex,pleas*ncleythe sled*immediately et 390-443 Mend aeemy tm repel prompty DOH Lab-Sample# /1 /} Theo mute Mete CityRemb the Rem weed and he see ele(e) 0�0• , //--� redeindty ee'abaaay.rna spat etel entice reproduced except Y V 1� in Keilho.it pier ewe.wden eppmed by Spectre teearaMlee. OO 1 Foam 6:331-110(Astor 01/17) Return To 2196556 MASON CO WA 05/01/2023 09:55 AM NOCE ru CC BRUFF IIIIIII III11111111111111111IIIlit III IIIIlittII I IIIN!IIIIII II IlIIIII 7.0. x .219, --17 Apo - W.'4 q85 d 8 Grantor(s): (1) ` XYI --hn)c1 , (2) Grantee(s): (1)PUBLIC Legal Description (1) Lora o 3132 )4141 2142152 PT71 0f S E (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) of off. 0 3 0 - 4 2 - e1 O O I a 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: 1`7 Maximum Annual Average Gallons Per Day: 9 5O gallons Dated on this 0— day of r 2T Signature of Grantor(s); (1)1S J ; / , (2) State of Washington ) County of Mason ,11111tiiifi111 NN•cr,.— Ss•,,' ti{4OTk9> m1.' MY C,Cfnnt _ tiOvernber rocs A22035237 Page 1 of 2 • WASH\ \\o• `����riiiiit1 ‘ I,the undersigned,a No Ty P,u lic in and for the a ove named County an State,do hereby certify that on this 12--- day of 20 personally appeared before me,who is known to be signer of the abo e 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 in and fort ate of Washington, Residing at /V‘-- My commission expires: //�/O 2196556 Page 2 of 2 05/01/2023 09:55:47 AM Mason County, WA