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Home My WebLink AboutWAT2023-00088 - WAT Application - 5/1/2023 • �J```i\�:c..t,f tY�kn• -MASON COUNTY r.6. 1 `` I• COMMUNITY SERVICESWATaoa.5 UOos 8 `,� Building,Planning,Environmental Health,Community Health !I).1ti 1,.0 415 N 6`1 Street, Bldg 8, Shelton WA 98584, A f Y S*elto: (3Ql t27-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 Elma: (360)482-T tpeciL Iv E D ENV t 1RO I v EN /�L FAX (360)427-7787 HEALTH Application for Determination of Water Adequacy MAY - 1 2023 Instructions 615 \N Alder Street 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: B1'Ctfct0Y\ \U1IE Date: 6/ 1/36a-5 Mailing Address: po F Q 1031_ ShettY1 Phone: . (0t-�1Q3 10�6 Parcel Number: -))') 2J. 1- 23 `1COI-- Type of Water System Reason for Application Public/Community Water System (2 or more 1t Building permit 12)t.49a63`,--cC4Ap xconnections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ 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: Vfttie 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. ❑ 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 Water Revised 1/25/2018 Individual Water Well Water well report (attached to application). Depth 11 Ci ft. ell capacity Test(attached to application) —1 S 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. ySatisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 15n 16(-122fl Water use or limitation recorded N/A = Yes Well Drilled Date � a4o a2 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: ,K 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: /Z4 /Environ. Health: \gikil Date / z3 '°' CSD Director: Date RECEIVED tS z 9' MAY - 1 2023 r1'VV�RON� 'tMENTAL7 615 W. Alder Street HEALTH WATER WELL REPORT y i DEPAS'MEN1 Of Notice of Intent No. WE45713 iirasa ECOLOGY Unique Ecology Well ID Tag No. BNV867 Type of Work: Viiilla State of Washington O Construction Site Well Name(if more than one well) ❑ Decommission -', Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Ben Jennings _ 0 Dewatcring 0 Irrigation 0 Test Well ❑Other Well Street Address Mason Lake Rd Construction Type: Method: E New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening ❑Other 0 Dug l)Air- 0 Mud-Rotary Tax Parcel No. 32126-20-04000 Dimensions: Diameter of boring 6 in.,to 179 ft Was a variance approved for this well? 0 Yes No Depth ofcomplcied well 179 R. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread f3 1 0 6 in. 0 174 0.25 in. O I 0 O I ❑ Location(sec instructions on page 2): O WWM or 0 EWM O 1 0 in. in. ❑ ( ❑ 0 I 0 SW .-1/4 of the NW Y..;Section 26 Township 21N Range 3W ❑ I ❑ in. _ _ in. ❑ I ❑ 0 I 0 O I ❑ in _ _ _in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.282828 N Longitude(Example:-120.12345) -123.031800 W Perforations: 0 Yes Gil No 'type of perforator used No.of perforations Sizc 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 str uctore,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ll Yes 0 No Ill K-Packer r-=> Depth 173 n. 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 174 ft.to 179 ft. Brown fine to medium sandy gravel,sill 0 Diameter Slot size in from ft to fl. bound,tight,dry 74 Brown fine to medium sandy gravel,gray silt 74 Sand/Filter pack:0 Yes ❑No Size of pack material in. Materials placed front ft.to. ft. binding,tight,dry 81 Surface Seal: WI Yes 0 No To what depth? 19 ft. Black sharp gravel,gray clay binding,tight,dry 81 93 Material used in seal Bentonite Chips Brown medium to coarse sandy gravel,loose 93 Did any strata contain unusable water? 0 Yes FT)No silty,wet 111 Type of water? Depth of strata Brown gravelly medium sand,active,wet 111 133 Method of sealing strata off Heaving coarse brown sand 133 139 Gray silt,stiff,dry 139 154 Pump: Manufacturer's Name Type: Gray silty brown fine sand,moist 154 157 H.P. Pump intake depth: ft. Desigted flow rate gpm Gray clay,stiff,dry 157 172 • Water Levels: Land-surface elevation above mean sea level 295 ft. Brown clay,stiff,dry 172 173 • Stick-up of top of well casing 1 ft.above ground surface Coarse sandy gravel to cobles,water 173 179 Static water level 75 ft.below top of well casing Date 7/26/22 • Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,value,etc.) Well Tests: Was a pumping test performed? ❑No 0 Yes c-7--.). by whom? Yield gpm with ft.drawdown after bus. 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 "lime Water Level Date of pumping test— Bailer test ppm with_ft.drawdown after hrs. Air test 75 gpm with stem set at 160 ft for 1 Ms - Date 7/26/22 Artesian flow gpm - Temperature of water 51 up Was a chemical analysis made? ❑Yes E No Start Date 7/26/22 Completed Date 7/26/22 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 O Driller G Trainee 0 PE-Print Name h Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsors License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 7/26/22 ECY 050-1-20(Rev 0918) If you need this document in an alternate format.please call the Water Resources Program al 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-634!. tbOantaS--0 7/fi 1786 SE Mile Hill Drive • � Port Orchard,WA-1 98366 ab.com RECEIVED SPECTRA Laboratories-Kicsap vvww.spectra -Y�fM nperMen menus (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM MAY - 1 2023 • Date Sample Collected Time Sample County • Collected aeon 515 W. Alder Street 8 I 16 ( 22 S pau Meet Dry Year --' ---• mp Type of Water System(check only one box) ❑Group A ❑Group B ['Other EN VI p o n! Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): N TA L EA TH System Name: Ben Jennings 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-ma) arleta@arcadladrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Mason Specific location where sample collected: Special instructions or comments: Well Head#BNV867 East Mason Lk Rd,Shelton Type of Sample(check only one box) 4 1.❑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 I I Unsatisfactory routine collect date: !_ 1 ❑Triggered Chlorinated:Yes❑ No❑ ❑Assessment Chlorine Residual Total Free 4. Enumeration Source Water Sample I S I ❑E.can ❑FBCal-Surface,OW,Spring's Ftiaed Yes❑ No❑ 5.['Serrpie Caected for Intormalbn Only LAB USE ONLY DRINKING WATER RESULTS LABU ONLY El Unsatisfactory Total Cottons Present and atisfactory ❑E.coli present ❑E.coli absent Replacement Sample Required: 0 Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Cdrform 1100 1.E.coli _ /100ml. Fecal Col'rform " 1 PC J1 ml. abl:Number � � �~ 10 _f n cy2 r'(n VC* Method Code: Date and Time Incubated: SM 9223 B AUGq AUG 17 2022 :ateAralyzed: A 1 8 LlJL2 DateRepo'ted: eiti6 Eifui _ t COH Lab.Sampal! Lab Use Only. 225 ._ •c5 crie skralr A p.1r;OJO�9 _ lsnenecnn�arAw me n;t +sY +eoarat ec.55.01 (marry ce; ( .,.. 6L09093--001-( k) MI � 2196595 MASON CO WA 05/01/2023 03:10 PM NOTCE BRANDON WOLF *186426 Rep Fee: S204.50 Pages: 2 All/ IHR11111111111111111HH0111Oh1111110Q11 Return To RECEIVED -Bc�antion A.Samna Wolf 10 lea MAY - 1 2023 Shtl{-on,Vfc c 358 F 615 W. Alder Street t`N\f!RoNMENTA HEATH L Grantor(s):(1) SanCitICl U)a,k" , (2) $rrkfdor\ uJo If. Grantee(s): (1) PUBLIC tot a of SP tstP pi l aacio3 Q'(f1 OF Legal Description (1) W 'ia VA `IA OF StiC• am A 1030' OF SEG ai (Abbmviated form:i.e. lot, block,plat or section, township, range) Fi Assessor's Tax Parcel: (1).3_a__ _a_La_-_a_a- l' ,,i2 Sav- ja‘-9.3 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) I (We), the undersigned grantor(s), hereby place this notice on record that the described real estate situated in Mason County, State of Washington is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These restrictions and conditions are based on location of property and/or Water Resource • Inventory Area or WRIA. WRIA: 1 `A 1?Maximum Annual Average Gallons Per Day: 57 gallons Dated on this day of , 20 Signature of Grantor(s): (1) , (2) I State of Washington ) County of Mason ) I Page 1 of 2 I, the undersigned, a Notary Public in and for the above named County and State, do hereby Cc�erttify_ that on his I? day of 111 , 20 ?-3 , ',rx�citla > 4 �-4 i r d 'Yak appeared before me,who is known to be signer of the above instrument, and acknowledged that he ( - , -slit. GIVEN under my hand and official seal the day and year las abov- -• l Notary Public for the State of Washington, residing at 0rn+'�IA My commission expires: V Z-7 NOTARY PUBLIC STATE OF WASHING ON • JOIfCESA DEVmS MIRESMr twos i OpµWON•1336$ • Page 2 of 2