HomeMy WebLinkAboutWAT2023-00039 - WAT Application - 6/23/2023 WAT OW
-.. • 5 �� 415 N.6t"Street
MASON COUNTY ` .L.r z...t " Shelton,WA 98584
r ) COMMUNITY SERVICES "l 3 20c�23 Shelton:360-427-9670,Ext.400
Bclfair:360-275-4467,Ext.400
j- Building,Planning,Fnvironmental Health,Community Health Elma:360-482-5269, Ext.400
F ' W. Alder Street
Application for Determination of Water Adecjtia RON MENTAL
Instructions H EAU H
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 AA
Name on Applicant: �Iltl;9 � b� Opt: v( Date: 2..5/Z07.0°3
Mailing Address: Sits DAV Sa•3 De. Phone: _l eO 5ry 7 1-4 1 r
Parcel Number: 11,031 11- 9 00 Sc.
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more K. Building permit <.J tx -VD RA,t)
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
xWell ❑ Boundary line adjustment
❑ Spring/surface water
❑ 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 (WEI) 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.
❑ 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:\EII Forms\Drinking Water Revised 4/27/2021
Individual Water Well
Water well report (attached to application). Depth n 1 ft.
`cfWell capacity Test (attached to application) O gpm t/ `'v 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://gis.co.mason.wa.us/planninq 14 15 16 22
Water use or limitation recorded N/A Yes Y
Well Drilled Date 6172/1 13
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)
ISatisfactory 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: COnviron. Health: \ Date CI 01 2�
This form may be scanned and available for public view at www.co.mason.wa.us.l
WATER WELL REPORT ,. I DEPARI MEN I OF Notice of intent No. WE52046
ECOLOGY Unique Ecology Well ID'Fag No. BPF087
Type of Work: State of Washington
O Construction Site Well Name(if more than one well):
fJ Decommission Original installation NOI No Water Right Permit/Certificate No.
Proposed Use: M Domestic 0 Industrial ❑Municipal Property Owner Name Dave Peterson
❑Dewatcring ❑Irrigation 0 Test Well 0 Other
Well Street Address 821 E Camden Way
Construction Type: Method:
J New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other 0 Dug lil Air- 0 Mud-Rotary Tax Parcel No. 120311290030
Dimensions: Diameter of boring 6 in.,to 171 ft.
Was a variance approved for this well? ❑Yes ❑No
Depth of completed well 171 it
Construction Details: WallIf yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
lH I 0 6 in. 0 166 .025 in. O I 0 O I 0 Location(sec instructions on page 2): 0 WWM or O EWM
O I 0 in. _ in. ❑ I ❑ ❑ I ❑ SW V.-Y.of the NE Y.;Section 31 Township 20N Range 1W
O I O in _ in. ❑ l ❑ DID
❑ I ❑ in. m. ❑ 1 ❑ ❑ I ❑ Latitude(Example:47.12345) 47.184517 N
Longitude(Example:-120.12345) -122.852097
Perforations: CI Yes ❑O No Type of perforator used
No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
Formation:Describe by color,character,size of material and structure,and the kind and
Perforated from ft.to ft.below ground surface
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: O Yes ❑No O K-Packer =� Depth 165 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.018 in.from 166 ft.to 171 ft. Brown gravelly fine brown sand,tight,dry 0 26
Diameter Slot size in.front ft.to R. Brown medium sand,dry 26 51
Brown sharp gravelly medium sand,silt 51
Sand/Filter pack:❑Ycs O No Size of pack material in. bound,dry 53
Materials placed from ft.to ft.
Brown medium sand,dry 53 61
Surface Seal: []Yes ❑No To what depth? 19 II. Brown pea gravelly medium sand,dry 61 78
Material used in seal Bentonite Chips
Did may strata contain unusable water? ❑Ycs F7 No Brown coarse sandy gravel,moist,tight 78 94
Type of water? Depth of strata Brown clay,stiff,dry 94 103
Method of scaling strata off Brown gravelly fine to medium sand,silty,dry 103 136
Brown fine tight sand,dry 142 153
Pump: Manufacmrer's Name Tyre Brown medium sandy gravel,wet,heaving,water 153 170
I I.P. Pump intake depth:_ft. Designed flow rate: gpm Brown clay,stiff,dry 170 171
Water Levels: Land-surface elevation above mean sea level 116 fl.
Stick-up of top of well casing 1 fl above ground surface
Static water level 110 ft.below top of well casing Date 5/22/23
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 =' by whom?.
Yield gpm with_ft.drawdown after hrs.
Yield _gpm with ft drawdown alter 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)
Tintc Water Level Time Water Level Time Water I.escl
Date of pumping test
Bailer test gpm with ft.drawdown after hrs. '
Air test 30 gpm with stein set at 160 ft for 1 his. - Date 5/22/23
Artesian flow gpm
Tbnupctautrc of water 51 'F. Was a chemical analysis made? ❑Ycs E No Start Date 5/22/23 Completed Date 5/22/23
WEt.t.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 infonnation reported above are true to my best knowledge and belief.
r3 Driller U Trainee U I'E—Prin <in• y Phythian Drilling Company Arcadia Drilling Inc.
Signature Address PO Box 1790
license No. 2053 City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License Contractor's
Sponsor's Signature Registration No ARCADDI098K1 Date 5/22/23
ECY 050-1-20(Rev 09/I S) If you need this document in an alternate format,please call the(later Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can cal!877-833-6341.
1786 SE Mile Hill Drive
Port Orchard,WA 98366
k, SPECTRA Laboratories-Kitsap www.spectra-lab.com
...IVIunt
CV`itnet1O"`r' (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
5 1 25 I 23 DAM00 Mason
4 : 0PM
Month Day Yea
Type of Water System(check only one box)
0 Group A 0 Group B :Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: Dave Peterson-821 E Camden Way,Shelton
Contact Person:Arleta Eisele/Arcadia Drilling
Day Phone: 360-426-3395 Cell Phone:
Email: arleta@arcadiadrilling.com Eve.Phone:
Send results to:(Print full name,address and zip code ore-mail)
arleta@arcadiadrilling.com __-_______
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name): flax
Specific location where sample collected: Special instructions or comments:
BPF087
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 ——— — ———
S 1 Unsatisfactory routine collect date:
1 I I
❑Triggered Chlorinated:Yes El No El
❑Assessment Chlorine Residual:Total Free_
4. Enumeration Source Water Sample I S I I
❑E.cols OFecal-surface.cim,SP a'js=clued re.D No
5.Q Sample Collected for Information Only
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
El Unsatisfactory Total Coliform Present and pfSatisfactory
❑E.coli present ❑E.coli absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑._ — ._—_
Bacterial Density Results:Total Coliform_ _ _ 1100m1. E.coli ___ /100m1.
Fecal Coliform /100m1. HPC -_ _ ___ /1 ml.
Lab ID Number � 1 �Y z s 2oz3 ((a �3 .
Method
Cod/,ear/}�� Date and Time Incubated:
SM 9223 B
Date Analyzed: /V%l Date Reported:
7 u , NAY 771IPT ,ti11b
DOH Lai Sample# 1 Lab Use Only:
0- on NJat-319 wt.".OV'a)-1l yell need Phis p Ac lc.n en itronVe karat.call axC 525.0177(rONi ry cal 711)
TAe and titer gNcalcna re ava4de et eve...dcRwapn+'trtrk,,,,,,
A1 /l
LOR023 -co ato
2194120 MASON CO WA
02/23/2023 02:11 PM NOTCE
PETERSON iF184502 Rec Fee: $204.50 Palg'e''IIs:IIIIII''2
Return To �1I���II I�����I��� v''.� a,.,
Nl_' \ L k v$o
get t f DAws«t t FEB 2 3 2023
PL. o� TX bra L15 W. Alder Street
ENVIRONMENT L
H EAU H
Grantor(s): (1) DEW+O C, E Somas , (2)
Grantee(s): (1).PUBLIC
Legal Description (1) TR 3 OF GOVT LOT 1 &TAX 753-A-1 LOT: B OF SP#1104 S47/63
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 1 2 0 3 1 _ 1 2 _ 9 0 0 3 0
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:
Maximum Annual Average Gallons Per Day: 6 50 gallons
Dated on this ,3 day of , 20 Z-^?
Signature of G an
i /
(1) , (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 2.3 day of cc b(K , 20 23 ,
Om i'd 4-2(Son 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 abo'tten.
..,„,„„....,....• -- ----'''''''' c6&
Notary Public Notary Public in and fog tll State of Washington,
State of Washington �/�/f �� � q�� /�"
ARIANEMPAYSSE residing at /'/aa21l C.4(.WAY
MY COMMISSION EXPIRES My commission expires: 1212°(/2,D 2 51229/2025
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