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HomeMy WebLinkAboutWAT2023-00126 - WAT Application - 6/6/2023 WAT -2(2 - CIO I2)Cp ,rk. __ MASON COUNTY COMMUNITY DEVELOPMENT r Permit Assistance Center,Building,Planning 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 Identification Name on Applicant: David Taber - Neiman Taber Arcl-Date: 06/06/2023 Mailing Address: 1435 34th Ave Seattle WA 98122 Phone: 206-760-5550 / 917-623-8401 Parcel Number: 22010-30-91002 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more El Building permitZit1 2-O2I'i DNA LP connections) 0 Division of land: (i Individual water source (one connection), #of Parcels? SPL (' D Well ❑ Boundary line adjustment 0 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) O 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. O 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 06/06/2023 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well E Water well report (attached to application). Depth 115 ft. p Well capacity Test (attached to application) 20 gpm > 3061 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. 1D Satisfactory bacteriological test(attach to application). r/2_ •/7,0 Z-z_ Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 10 15f 16(—(22= Dix Water use or limitation recorded N/A'm' Yes I V AFA/:�'19 Well Drilled Date 9/8/22 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 40-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requipl p . Chapter 36.70A RCW. V f`J Unsatisfactory Determination: UU �� Applicant's water supply does not appear adequate to meet the needs of its intended usenl4th0,lICCUU J 9 g reason(s). MgSpNCOUNTYENVI Ro Reviewer's Signatures: DJA NMENTAL HEALTH Environ. Health: Date 78/Z Zi 2 of 2 CSD Director: Date 1 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com —Wiwi,"oe"tKe mom. (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 9 f 20 I 22 3 50 �AN Mason 0 PM Mont Dry Yw` -------_- -- —_ Type of Water System(chec(only one box) ❑Group A ❑Group B 00ther Group A and Group B Systems—Prodde from Water Facilities Inventory(WFI): ID# — System Name: Forest Majeure,LLC Contact Person:Arleta EiselelArcadia Drilling Day Phone: 360-426-3395 Cel Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send results to.(Print lull name,address and zip code a e-mail) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):itfillX Specific location where sample collected: Special Instructions or comments: #BNV853 COUNTS PLEASE 520 E South Island Drive,Shelton Type of Sample(check only one box) --_ 1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No 0 0 Distribution System Chlorine Residual:Total_Free_ Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample — ——— S l 1 Unsatisfactory routine collect dale: f 1— ❑Triggered Chlorinated:Yes ElNo❑ Chlorine Residual:Total Free ❑Assessment 4. Enumeration Source Water Sample I S ill ❑E.coil [Fecal-Srim,GN,,spent Filtered Yes NoDI 5.0 Sample Collected ton Information Only: -- LAB USE ONLY DRINKING WATER RESULTS LAB SE ONLY ❑Unsatisfactory Total Coliform Present and atisfactory ❑E.coli present 0 E.coli absent Replacement Sample Required: Gad tor. 0 Sample too old(>30 tours) 0 TNTC e�❑ -- Bacterial Density Results:Total Coltorin i ►rip i 1110Omi. E.cofi aM 100m1. Fecal Colifonn__ - 1100m1. HPC___ /1 ml. Lab ID Number Date and Method Code: Da:e and Time Incubated' SM9223B LULL gnggReported' 9//I L22 Date Analyzed. SEP 2 2 Date Reported SEP 2 ? 1022 DOH Lab-Sample 5 O Lab Use Only: 225 - (_A - -_1__ OH Far.101131;ee.co-n OYti;•aro need Fie Cv'.klL-Inan iemr6.e IrnnK c4E00525.O1v(rCOM cm,I It..rd X+er pAketr.re.,in,et Aee dolt**crrd6vbr.?vSH immommommomulimmignier WATER WELL REPORT r-� DEPARI MENT OF Notice of Intent No WE49142 ECOLOGY Unique Ecology Well lD Tag No. BNV853 Type of Work: State of Washington E. Construction Site Well Name(if more than one well): ❑ Decommission r- ' Original installation NOI No. Water Right Permit/Certificate No. Proposed Ilse: ©Domestic 0 Industrial 0 Municipal Property Owner Name Catherine Major ❑Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 520 E South Island Drive Construction Type: Method: O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug fil Air- ❑Mud-Rotary Tax Parcel No. 22010-30-91002 Dimensions: Diameter of boring 6 in,to 115 ft Was a variance approved for this well? 0 Yes O No Depth of completed well 115 ft Construction Details: Wall yes,what was the variance for? Casing Liner Diameter From To 'thickness Steel PVC Welded Thread IA I 0 6 in. 0 110 .025 in 171 I 0 O I El Location(see instructions on page 2). IA WWM or 0 EWM ❑ I ❑ in. '" ❑ I ❑ ❑ 1 ❑ SW 'Y-Y.of the NW ''h;Section 10 Township 20N Range 2W ❑ I 0 in. _ in. ❑ I ❑ ❑ 1 ❑ ❑ I ❑ in. in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.235003 N Longitude(Example:-120.12345) -122.924528 W Perforations: 0 Yes ©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 fl 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: lEl Yes 0 No lil K-Packer r-> Depth 109 fl. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5" Slot size.014 in.from 110 ft to 115 ft Brown gravelly fine sand,tight,dry 0 9 Diameter Slot size in.from ft.to R. Brown fine sandy gravel,silt bound,tight,dry 9 33 Brown fine to medium sandy gravel,tight,welps 33 66 Sand/Filter pack:0 Yes ❑a No Size of pack material in. Materials placed from ft.to ft. Black fine silty sand,heaving 66 74 Black fine to medium sandy gravel,tight,wet 74 76 Surface Seal: O Yes 0 No To what depth? 20 ft Gray clay,stiff,dry 76 98 Material used in seal Bentonite Chips Did any strata contain unusable watery ❑Yes El No Black gravelly medium sand,heaving,water 98 115 Type of water? Depth of strata Black clay like silt,soft 115 115 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 56 ft. Stick-up of top of well casing 1_4 fi.above ground surface Static water level 51 ft.below top of well casing Date 9/8/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? O No ❑Ycs r-:> by whom? Yield gpin with ft.drawdown after hrs Yield gpm with _ ft.drawdown after hrs Yield gpin 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 100 ft.for 1 hrs. - Date 9/8/22 Artesian flow gpm Temperature of water 51 °F Was a chemical analysis made? 0 Yes O No Start Date 9/8/22 Completed Date 9/8/22 WELL CONSTRUCTION CERTIFICATION: I constricted 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 O Driller❑Trainee 0 PE—P me Rogeray Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Lie o. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 9/8/22 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 71l for Washington Relay Service. Persons with a speech disability can call 877-833-6341. 2197938 MASON CO WA 06/06/2023 09:58 AM NOTCE 111111 I11N1IIIIIMliiIIIIIMIIIIIPIIIR IIIIIIIIIII�IIIIIIIIIIIII1I s 2 Returniio AA ,,�� C� e rt P A116-(p sew (. cal gk101 Grantor(s): (1) C 0"1--r'✓1 tv2, 44(��(c.� �, (2) Grantee(s): (1) PUBLIC J Legal Description (1) 1_1) /- 02. D I `,?P 2 in r10 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) d► a n I n - 3 0 - I O U oZ S10 i 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`1 Maximum Annual Average Gallons Per Day: 00 gallons Dated on this day of91-44'\4-- , 20 7-.3. Signature • Aff: (1) Add i / , (2) State of Washington / County of Mason ) Page 1 of 2 I I,the undersigned, a Notary Public in and for the above named County and State, do hereby cert. that on this�t�day of ►et, , 20 23 , (`na3:v 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 and year last above written. ,cOa i m 1�di S 0`„%%%%% ,,tt,,,,t� Notary Public inl and //for the State of Washingto , _.•`• S��� EioM residing at k LQ La )22 o'1.KOFARY �p�: My commission expires: DI/36 N• 21009497 =NJ; PUBLIC /. . Page 2 of 2