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HomeMy WebLinkAboutWAT2023-00118 - WAT Application - 12/19/2022 I - WAT 202 - QO I I e< '` MASON COUNTY .". > COMMUNITY SERVICES Buddmg.Glannirxy Environmental Health.Community Health 415 N 6th Street,Bldg 8,Shelton WA 98584, Shelton: (360)427-9670 ext 400 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 ,,Identificatio Name on Applicant: /C /1) Q/(h- order' Date: /g//f/ Z2 Mailing Address: C ZI l`U i e. kr(4 010 one: _FAO Parcel Number: 720Z It 2 '-0 Z 7.O' Type of Water System Reason for Application ❑ Public/Community Water System (2 or more i ' Building permit :DIC12o23 — Cb57rivt( Lp onnections) 0 Division of land: Individual w r source (one connection), #of Parcels? SPL Le Well 0 Boundary line adjustment 0 Spring/surface water 0 Other (explain) 0 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. 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. 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 dater Re%itied I25'2018 Individual Water Well er well report (attached to application). Depth ( �at 7ft. Well capacity Test (attached to application) gpm ' 80 0 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 1 /by a licensed contractor. i Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/olanninq 14 /' 15 16 22 Water use or limitation recorded N/A Yes Well Drilled Date 5/10 1 Z=- 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 r uirements ma ap ly ter 36.70A RCW. A PR V Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended .sg'fo �ctlJpeing reason(s). _JN b Reviewer's Signatures: MASON COUNTY 7.''/''�.�/ 4 E: . Environ. Health: 171-------- Date 6/Lr 7Ul3 CSD Director: Date .of'- WATER WELL REPORT b...ineDEPARTMENT OF Notice of Intent No WE44769 ECOLOGY Unique Ecology Well ID Tag No. BNX220 Type of Work: la State of Washington l Construction Site Well Name(if more than one well) D Decommission ; Original installation NOI No. Water Right Pt-mit/Certificate No. Proposed Use: ©D omcsnc ❑Industrial O Municipal Property Owner Name Benjamin Sanders 0 I ewawing 0 Irrigation 0 Test Well 0 Other Well Street Address 901 E Lansky Dr Construction Type: Method: O New well 0 Alteration ❑Driven ❑Jutted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other- O Dug lid Air- 0 Mud-Rotary Tar Parcel No. 22024-20-02070 Dimensions: Diameter of boring 6 in,to 297 ft Depth of completed well 297 ft Was a variance approved for this well? 0 Yes 0 No Construction Details: Wall If yes,what was the variance for? .J Casing Liner Diameter Front To Thickness Steel PVC Welded Thread IA 1 0 8 in. 0 397 0.25 in 3 I 0 O 1 ❑ Location(see instructions on page 2): 0 WWM or❑EWM ❑ 1 0 in _ m ❑ I O ❑ 1 ❑ SE y%of the NW %;Section 24 Township 20N Range 2W ❑ 1 ❑ in. _ _ _in ❑ 1 ❑ ❑ 1 ❑ ❑ 1 ❑ in _ _in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.207728 Longitude(Example:-120.12345) -122.882971 Perforations: O Yes lii No Type of perforator used No of perforations Size of perforations in by_in. Driller's Leg/Construction or Decommission Procedure Perforated born ft to ft below ground surface Format ion 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: O Yes 0 No 0 K.-Packer Depth ft mforrnation. Use additional sheets of necessary. Manufacturer's Name Material From To Type Model No Diameter Slot size_in.from A to_It. Brown sdty sand and gravel 0 31 Diameter_ Slot size as from _A.to A. Brown fine to medium sand,gravel,loose 31 128 -"- Brown fine sand,silt 128 156 Sand/Filter pack:0 Yes 0 No Size of pack material in. Materials placed hour fl.to ft. Brown fine sand,silt,wet 156 189 Gray silt 189 193 Surface Seal: hI Yes 0 No To what depth? 20 fl. Gray fine sand,silt,wet 193 213 Material used in seal Bentonite Chips Didany strata contain unusable water' 0 Yes 0 No Brown fine sand,silt,peat 213 216 Type of water' Depth of strata Brown silty day 216 220 Method of sealing strata our Multicolored pea gravel with gray clay binder 220 226 Gray sift 226 240 Pump: Manufacturer's Name Type. Gray medium to coarse sand,some gravel 240 244 II.P. Pump intake depth: A. Designed Bow rate._gpm Gray medium to coarse sand 244 258 Water Levels: Land-surface elevation above mean sea level 240 A. Multicolored gravel,medium to coarse brown 258 Stick-up of by of well casing 1 A.above ground surface Sand,loose,wet 279 Static water level 222 ft below top of well casing bate 5/10R2 Artesian pressure lbs per square inch Date Multicolored gravel,brown,medium to coarse 279 Artesian water is controlled by (cap.valve.etc I sand,tight,water 297 Well Tests: Was a pumping test performed? Pt No ❑Yes ,- by whom" Yield gpm with_A.drawdownAlin his Yield gpm with ft.drawdownalter his Yield gpm with A drawdown alter Ins Recovery data(time zero when pump is turned off water Ssl measured from well lop to water level) Time Water Level Time Water level Time Rater Level Date of pumping test Rader test test gpm with f drawdown after_his 1 Arc test 20 gpm with stem set at 280 ft for 1 his , Doc 5110/22 Artesian flow gpm Temperature of water 51 •F Was a chemical analysis made? 0 Yes 0 No Start Date 5/9/22 Completed Date 5/10/22 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 ▪Driller O Trainee O PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 V City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No ARCADDI098K1 Date 5/10/22 ECY 050-1-20(Rev 09/18) If you need this document in an altemale formal,please call the(Pater Resources Program at 360407-6872. Persons with hearing loss can call 7//for Washington Relay Sen•ice. Persons with a speech disability can call 877-833-6341. 1 2197418 MASON CO WA 05/23/2023 09:25 AM NOTCE BENJAMIN SANDERS *167073 Rec Fee: 5204.50 Pages 2 Return To I IIIIIIi llll 11I IIIIIII II IIII I�IIII III I IiII i I IV N lIII III 10 Vl n7 pm rl v WW1 krci . Of- gri5D Grantor(s): (1) Ben j6_min ()Ct_n ie.i S , (2) Grantee(s): (1) PUBLIC Legal Description (1) f' . 7 or �? %2, (1 L (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) ;21 2. - 2, b - D U .7 U 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: I Maximum Annual Average Gallons Per Day: ! 50 gallons Dated on this ZJ day of /"47 , 20 a . Signature of Grantor(s : (1 / �� `v , (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 certify that on this z day of YYl , 20Z.3 , pelisonally 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 and year last above written. DQ,,f ,ENE M Notary Public in and for the State of Washington, OQs •`siON fp<Cs residing at VIQ L A l g o NOTARY r. • U• 21009497 My commission expires: f) 136 JZv2rj • N� pUBUO /. . °' op WAsNAa, , Page 2 of 2 ,) ,Daeic23 - CZ524' Thurston County Environmental Health 2000 Lakeridge Dr. SW t Olympia,WA 98502 l.D _-_- 360 867-2631 THURS7�0®Y Q C COLIFORM BACTERIA ANALYSIS 202'3 Date Sample Collected Time Sample County MQ� 25 SC /- /o/ w Collected " M eC rV1 `� 7- , 7/kCik `n I 06 Month Day Year O?M �jA 5 v •V Type of Water System(check only one box) ❑ P vateO�Iuseold�{� l,,J ❑Group A ❑Group B Othery rA G l` ���AV( Group A and Group B Systems—Provide from Water Facilities Invenrory(WFI): ID# System Name: ENVIRONMENTAL ContactPerson:I jQ/7fk d""'r `` ' EN `�H Day Phone:( ) `�! Cell Phone:(e/ ), -- H EA E maij�F j�lC!I d�LpC J^�� ` :�� ve.Phone:( ) Sen r tilts to:(Print full ,amejddres,s,and zip r email address) i2it di e/fi,t SAMPLE INFORMATION Sample collected by(name): -am 41(06\ S ecificr location or address where to collected: t�pecial�instruc Qns e�or comments: r���`t�� Gr/ 4 ga-if lam( t Type o mple(must check only one box of#1 through#4 listed below) 1. Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coli—GWR(A/P) ❑Fecal—Surface,cwi,springs4humeralion) Unsatisfactory routine lab number: Filtered:Yes No - ❑Assessment Monitoring(AJP) Unsatisfactory routine collect date: ■. . agN30� S / c O alkBample ollected for Information Only GtU� IC Y'InvestigatAfe Construction/Repairs Other >`.1LAB tl,SE.ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and attsfactory ❑E.coli present ❑E.coli absent No liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli 1100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code:tirM 9223E ❑SM 9222D Date and Time Received: ❑SM 9215E ❑Enterolert® 5 -2c4--'Z3 Dct3'S Date and Time Analyzed: 5--24 2') Date Reported 'ZS 2_3 )(, Sample Number(DOH number plus five digits) Lab Use Only' o 8 0 - 2._ s i 0g S.pet aP cey.I s-z5-7.3 -XI DO m e331.319 revised 01116) IC)