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HomeMy WebLinkAboutWAT2023-00075 - WAT Application - 4/18/2023 I W AT ZO 2. ? - O6015 ,,, ,....t RECEIVED 415N.6thStreet MASON COUNTY Shelton,WA 98584 ‘01117'.-,\ F COMMUNITY SERVICES APR 18 2023 Shelton:360 427-9670,Ext.400 ..; Belfair:360-275-4467,Ext.400 `` � P.uilding Planning Fnviron mental Health,Community Health Elma:360-482-5269,Ext.400 615 W. Alder Street 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: !M.( i VlAA f.�itkilV\ Date: 4 .1 1-3 Mailing Address: 11 . DYtl rh S 4j VV. Phone: 3 0• 144• e/'Sa Parcel Number: 4111,1 - UI- l 0 0'W Type of Water System Reason for Application ❑ Public/Community Water System (2 or more g Building permit c 262.3-Ong 15 connections) 0 Division of land: Sk Individual water source (one connection), #of Parcels? SPL X Well 0 Boundary line adjustment ❑ Spring/surface water 0 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:AEll Forms\Drinking Water It v i-,ed-1 2'2112I ..,A Individual Water Well 4Y ater 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. VSatisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 15_ 16_22_ Water use or limitation recorded N/A Yes y Well Drilled Date 1 MI- I 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. 1 Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s) ,R, 1 Reviewer's Signatures: �� Environ. Health: \L.11\4 �'V Date s t I This form may be scann Cd and available for public view at www.co.mason.wa,us. Page 2 of 2 WATER WELL REPORT DEPARIMENI Or Notice of Intent No WE42362 ECOLOGY Unique Ecology Well ID Tag No BNX126 Type of Work: Mate of Washington O Construction Site Well Name(if more than one well) 0 Decommission `J Original installation NOI No. Water Right Permit/Certificate No_ ProposedUse: IB Domestic ❑Industrial 0 Municipal Property Owner Name Mike Eaton ❑Lewatcnng Cl Irrigation CI Test Well 0 Other Well Street Address Northern Sky Dr Construction Type: Method: New well ❑Alteration ❑Dnven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug O Air- El Mud-Rotary Tax Parcel No. 42127-11-90020 Dimensions: Diameter of boring 6 in,to 79 ft. Was a variance approved for this well9 ❑Yes ❑No Depth of completed well 79 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From T. Thickness Steel PVC Welded Thread • I 0 6 in 0 79 0.25 in O I ❑ EIO Location(see instructions on page 2): WWM or 0 EWM ❑ 1 ❑ in _ in ❑ 1 ❑ ❑ 1 ❑ NE '/.-V.of the NE /.;Section 27 Townsh p 21N Range 4W ❑ 1 ❑ in _ _ in 0 I 0 ❑ I ❑ ❑ 1 0 _in in ❑ 1 ❑ ❑ I ❑ Latitude(Example:47 12345) 47,286752 Longitude(Example:-120.12345) 123.167923 Perforations: fl Yes ©No Type of perforator used No.ofperforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure _ft. _ Formation:Descnbc by color,character,size of material and structure,and the kind and Perforated from to ft below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes 1C No ❑K-Packer ` l Depth ft. information Use additional sheets if necessary Manufacturer's Name Material From To Type Model No. Diameter Slot size_in.from fl to ft Brown silty sand&gravel cobbles 0 3 Diameter Slot size in.front ft to ft. Brown medium sand,gravel 3 17 Large gravel,coarse brown sand,loose 17 24 Sand/Filter pack:❑Yes O No Size of pack material in. Materials placed from ft.to ft Brown silty sand&gravel,wet 24 53 Brown fine sand,wet 53 55 Surface Seal: O Yes 0 No To what depth? 19 ft Multicolored gravel,coarse brown sand,loose, 55 Material used in seal Bentonite chips Did any suata contain unusable water? CIYes LI No water 79 Type of water" Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type. H.P. Pump intake depth: ft. Designed flow rate:_ gpm Water Levels: Land-surface elevation above mean sea level 270 ft. Stick-up of top of well casing 1 ft above ground surface Static water level 28 ft below top of well casing Date 7/9/21 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc Well Tests: Was a pumping test performed" O No 0 Yes C), 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 Lerel - — Date of pumping test Bailer test_gpm with_ft.drawdown after hrs Air test 20 gpm with stem set at 60 ft.for 1 hrs - Date 7/9/21 Artesian flow gpm Temperature of water 50 °F Was a chemical analysis made? ❑Yes O No Start Date 7/9/21 Completed Date 7/9/21 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards Materials ttsed and the information reported above are true to my best knowledge and belief E Driller 0 Trainee 0 PE-Print Nam osh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No 2874 !0 d u City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature Registration No ARCADDI098K1 Date 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. 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com -.,inter..expert...,matters (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 4 4 23 4 00 ❑nM Mason • Month Day Year —to PM • Type of Water System(check only one box) ❑Group A ❑Group B :Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): IDS , System Name: Mike Eaton Contad Person:Arleta Eisele/Arcadia Drilling Day Phone: 360426-3395 Cell Phone: Email: arleta@arcadiadriiling.com Eve.Phone: Send results to:(Print full name,address and ip code ore-ma) a rleta@arcad iad ri l l i ng.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Se ff Specific location where sample collected: Special instructions or comments: #BNX126 11 East Northern Sky Drive,Shelton Type of Sample(check only one box) 1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ ❑Distribution System Chlorine Residual:Total_Free_ Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample _ __ - S I 1 I I Unsatisfactory routine collect date: / I ❑Triggered Chlorinated:Yes ElNo El ❑Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample IS I I 1 ElE.Coll ['Fecal--Berate,GM,Springs-Filleted Yes ElNo❑ 5.0 Sample Collected for Information Only. LAB USE ONLY DRINKING WATER RESULTS USE ONLY ❑Unsatisfactory Total Coliform Present and factory ❑E.colipresent ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC 0_ Bacterial Density Results:Total Coliform __ /100m1.Ecnfi_ _-1100ml. Fecal Coliform /100m1. HPC /1 ml. Lab ID Number Date ardTime ived: 2..z�S?y -o( 4f/d23 /6If0 Method Code: Date and Time Incubated: SM 9223 B Date Analyzed: APR 5 20'J Date Reportldlrf i i 6 DOH Lab-Sample# Lab Use Only-. P1 2.2f:D1DS7'1 DOH Mom 331319 Inflects*}Yle)•II you need fit Mt9 nn.Ilen*.knelt cal K0.526.0127 ITOOrTY Cell 71 II nee end other;d<.eon es matte/...d11op>ImNmpeoter 4 2196113 MASON CO WA 04/ta�. ears fw r10TCE I Return To mtY.E- Liinn Won it s VIOkhan sky- 5hut401. kdA 'iS'! Grantor(s):(1) tAINA Y , (2) Grantee(s):(1)PUBLIC Legal Description (1)14 2 aSo(y AFek iclua 03 'MTh ac r+e AE S1/45 (Abbreviated form:i.e. lot,block,plat or section, township, range) Assessor's Tax Parcel: (1) 4 .�. 1 A 1 - I ( - C 0 O or2 o 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: 14 Maximum Annual Average Gallons Per Day: 1150 gallons Dated on this (q fi day of tkrik, ,20 Signs re of Grantor(s): (1) �/11L,`�'� , (2) State o Washington ) County of Mason Page 1 of 2 I, the undersigned, a Notary Public'n and for the above named County and State, do hereby certify that on this (Wlday of iQ(I) ,20,23 , L Jj p� 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 d year last above writte . , (Olte4iki/ 1< Ju1, 7cM ? Notary Public in and for the State of Washington, residing at aro (k4 L Lil/7f My commission expires: Z jys'1 2Q2 S'. 1 CATHERINE A SWENSON Notary Public i State of Washington License Number 15656 My Commission Expires February 15, 2025 Page 2 of 2