Loading...
HomeMy WebLinkAboutWAT2023-00073 - WAT Application - 4/17/2023 ENVIRONMENTAL HEALTH WATG2CSa23 - OOO73 u `J� L..." 415 N.6'h Street MASON COUNTY 1�• Shelton,WA 98584 ("77 COMMUNITY SERVICES "n Shelton:360-427-9670,Ext.400 APR 7 2� Belfair:360-275-4467,Ext.400 Building,Planning,Environmental 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 IdentificationJi Name on ApplicanrcirCk ', Cj,��,� Date: I 7 a R3 Mailing Address: �J E6, m&, }q� Phone: & 3 - 8 Q - 7O y 1 � S Parcel Number: 39,(:)\5—94 — Dad'b Type of Water System Reason for Application 0 Public/Community Water System (2 or more 4St" Building permit 61-0Rdo2�—OC4/08 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL lir Well ❑ Boundary line adjustment 0 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. 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:\EH Forms\Drinking Water Revised 4/27/2021 Individual Water Well Water well report (attached to application). Depth W v ft. T Well capacity Test (attached to application) t gpm 7 U 0 (3 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. 7 Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14 X- 15 16 22 Water use or limitation recorded N/A Yes V Well Drilled Date 3 ag/aaa,3 Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection 0 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) s-'1( 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: '16-- Environ. Health: r�,-/) Date 5J 5o (22) This form may be scanned and available for public view at www.co.mason.wa.us. Page 2of2 r'. r:or'10i"r...Z.0 Ot.i9RoR 3 -Doti 06 1. ENVIRONMENTAL 7 202,1 HEALTH 1-,, `\ G�5 �"�1. pI.d& Street WATER WELL REPORT ,.. ,. DEPARTMENT Of Notice of Intent No. WE51851 ECOLOGY Unique Ecology Well ID Tag No. BPF096 Type of Work: State of Washington © Construction Site Well Name(if more than one well): O Decommission r_r• Original installation NOI No Wafer Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Tracy Rouse 0 tewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 1122 Crestview Dr Construction Type: Method: O Now well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other El Dug III)Air- 0 Mud-Rotary Tax Parcel No. 320154400010 Dimensions: Diameter of boring 6 in.,to 209 R. Was a variance approved for this well? 0 Yes ❑No Depth of completed well 208 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread © I 0 6 in. 0 2oe .025 in. E4 I 0 O I 0 Location(see instructions on page 2): ©W W M or❑EWM ❑ I 0 in. _ _ in. 0 I 0 0 I 0 SE /.-t/.ofthe SE %;Section 15 Township 20N Range 3W ❑ 1 ❑ in _ in. ❑ I ❑ ❑ 1 ❑ O 1 ❑ in _ in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.214667 N Longitude(Example:-120.12345) -123.037351 W Perforations: 0 Yes Of 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_R.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 catty for each change of Screens: ❑Yes 9 No 0 K-Packer Depth ft. infonnation. Use additional sheets if necessary. Manufacturer's Name Material horn To Type Model No. -- Diameter Slot size in from II.to_R Brown fine sandy gravel,silt bound,tight,dry 0 16 Diameter Slot size in.from R.to_ft. Black fine sandy sharp gravel,gray silt bound, 16 Sand/Filter pack:0 Yes O No Size of pack material in tight,dry 22 Materials placed from ft.to R. Brown fine sand,loose,dry 22 37 Brown gravelly fine sand,dry 37 45 Surface Seal: J Yes CI No To what depth? 20 ft. Brown fine sand,dry 45 86 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes ElNo Brown clay-like silt,stiff,dry 86 99 Type of water? Depth of strata Gray silty clay,stiff,dry 99 107 Method of sealing strata off Brown fine silty sand,moist 107 112 Brown medium fine sand,wet 112 127 Pump: 'Manufacturer's Name Type: Gray silty clay,stiff,dry 127 134 H.P. Pump intake depth:_R. Designed flow rate:_gpm Black sharp gravelly gray silty clay,tight,dry 134 164 Water Levels: Land-surface elevation above mean sea level 201 ft. Gray day,stiff,dry 164 173 Stick-up of top of well casing 1 ft.above ground surface Green clay,stiff,dry 173 184 Static water level 156 ft below top of well casing Date 3/28/23 Artesian pressure lbs.per square inch Date Black pea gravel,tight,wet 184 196 Artesian water is controlled by (cap,valve,etc.) Black pea gravel with medium sand,wet,tight 196 204 Black coarse sandy gravel,tight,water 204 209 Well Tests: Was a pumping test performed? ]No 0 Yes =-> by whom? Brown peat and gray clay,stiff,dry 209 209 Yield_gpm with_fl 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 front 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 15 gpm with stein set at 195 R for 1 hrs. - Date 3/28/23 Artesian flow gpm _ Temperature of water 51 'F Was a chemical analysis made? 0 Yes ©No Stan Date 3/28/23 Completed Date 3/28/23 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. J Driller❑Trainee 0 PE .-Ogeray Phythian Drilling Company Arcadia Drilling Inc. Signature f 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 3/28123 ECY 050-1-20(Rev 09/18) limn creed this document in an alternate format,please call the(later Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Iashington Relay Service. Persons with a speech disability can call 877-833-6341. s b1 n 20 a 0°( ) O B 1786 SE Mile Hill Drive l►.2/ (JI, IJIJ''( Port Orchard,WA 98366 j SPECTRA Laboratories-Kitsap www.spectra-lab.com -Mitre experience ae,,<.. (360)443-7845 RE tom...I r COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County ;! iZ 17 2U23 4 I 3 / 23 Collected 2 00 o"" Mason Month Day Yea —.mom 615 W. Alder Street Type of Water System(check only one box) ❑Group A ❑Group 8 ['Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): • ID# `, M ENTA System Name: Tracy Rouse V,t RON Contact Person:Arleta Eisele/Arcadia Drilling BEALTH Day Phone:360.426-3395 Cell Phone: Email: arleta@arcadiadriiling.com Eve.Phone: Send results to:(Print lull name.address and zip code or e-mail) arletatlarcadiadrilting.com . Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Seth Spec&c location where sample collected: ' Special instructions or comments: #8PF096 1122 Crestview Drive,Shelton Type of Sample(check only one box) 1.0 Routine Distribution Sample 12.Repeat Sample(after unsat.routine) • Chlorinated:Yes❑ No❑ 0 Distribution System Chlorine Residual:Total_Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample ISI I I Unsatisfactory routine collect date: 1]Triggered Chlorinated:Yes ElNo El ❑Assessment Chlorine Residual:Total_Free^ 4. Enumeration Source Water Sample ISI I ❑E.cci GY['Fecal-Surface, N.Sprigs Filtered Yes El No ❑ Il 5.[J Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ( ctory ❑E.coipresent ❑E.coil absent Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑__. Bacterial Density Results:Total Colifam ...-----...-._/100m1. Ecoli._ /100ml. Fecal Coliform 1100m1. HPC J1 ml. Lab ID Number Date and lime Received: 2.2sk(62-, 01 Method Code' Date and Time Incubated: SM 9223 B c.t/C.fr/Z3 Date Analyzed: 1 //�J,z/'7, Do _ e ort4j 12, DOH 1. Sample# Lab Use Only: - 0/0 1K12 ,( °L DOH Foam p31-319NOeaa 0e161-d ,needOap ll:Moena elrea+e+rmg saes D2.0127(MOO1TfY cd 711} Thk and ida pAkkaese ra e*it we,.hnrepwrdiardapwtr. 2196435 MASON CO WA 04/27/R023 1M:28 RM NOT i : 0 . 2TRAIYllUIE I1II 6 II 04 SIPalsI Return To ;� I rg C`/ R a u ,S--e ,s-0 L1 i- r )U-14 a9 OL' l/hadJ 7-os s 12 0, L4 cm (s.�� Q 0 Grantor(s): (1)-17- � "�nL7 uC .//(2) Grantee(s): (1) PUBLIC Legal Description (1) TR 1 IN SE SE EX 3' IS `f' ., O R3 (A naviated rm:i.e. lot, block, plat or section, township,range) Assessor's Tax Parcel: (1 _� 1 5 - 4 4 - 0 0 0 10 9 TITLE NOTIFI O WATER RESOURCE INVENTORY AREA (WRIA) I (We), the undersi ed gr qt s), hereby place this notice on record that the described real estate situated in son C Onty, State of Washington is subject to water use restrictions and conditions set n State Senate Bill 6091 and Mason County Code 6.68. These restrictions d co itions are based on location of property and/or Water Resource Invent° e WR1A. WRIA: / 1 (ax1n'urn Annual Average Gallons Per Day: 950 gallons ted on this day of �p c i l , 20, 1 . nature of Grantor(s): (1) /6[ r�a"2.3, --(z_sz.__ , (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public in and for the above named unty and State, do hereby certi that on this ,/ day of 4.r f I , 20,� 3 , Ira c y 1 R rite Se_ personally appeare ore. e, who is known to be signer of the above instrument, and acknowledged that he. -) (th6fYsigned it. GIVEN under my hand and official seal the day and ye-r as 5.eve written. Note" Public and for the State of Washington, Ezoz 'b l Aew se4x3 •wwop Aw EbOLL ft uo;sslwwo) in - 4 & ,y t+ uol5ucyseM;o alel$ -- /l?/ ggnd f,JMN My co fission expires: '; cnno2 inoo V VCNII N___ Page 2 of 2 • 2196435 Page 2 of 2 04/27/2023 11:26:36 AM Mason County, WA