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HomeMy WebLinkAboutWAT2023-00125 - WAT Application - 11/30/2022 WAT c 6,29j - et,, 12 .. MASON COUNTY 415N.6d'Street ~� Shelton,WA 98584 ''� COM:MUN1'1'Y SERVICES ;:z ,:_i�`�`,; Shelton:360-427-9670,Ext.400 %`—"�','/ Baking,Planning,Environmental Health,Community Health Betfair 360-275 1�67,Ext 400 ,trr1is?` Elma:360-482-5269,Ext 400 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 1 _ Name on Applicant: 61 �DS Le-� Date: tp -, - ,• . Mailing Address: 226 ail kL r1 n Phone: ,3_ (Q_72/5 . 6+" f Parcel Number: nn1111 / r - U h Iv.f.1VJl PL , wGL. l 8`71C.tt.O Type of Water System Reason for Application • 0 Public/Community Water System (2 or more Building permit Ill 2023- CO-02 i Xconnections) 0 Division of land: lfldlVideiival ter source(one connection), #of Parcels? SPL ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) 0 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) 0 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:\EE Forms\Drinldng Water Revised 4/27/2021 Individual Water Well 9-Water well report(attached to application). Depth ` OZ ft."10 Well capacity Test(attached to application) Ve) gpm -7 O ()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 by a licensed contractor. Jt 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 X Well Drilled Date Ct((-7 f--erc Individual Spring/Surface Water O 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) 10 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: Environ. Health: n \ Date 1 r/ 4 (-CATS This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 WATER WELL REPORT ►% '4 DEPARTMENT OF Notice of Intent No. WE49093 vlik ECOLOGY Unique Ecology Well ID Tag No. BLN197 Type of Work: State of Washington © Construction Site Well Name(if more than one well): O Decommission . Original installation NOI No. _ Water Right Permit/Certificate No. Proposed Use: ®Domestic 0 Industrial ❑Municipal Property Owner Name SKYLER BOSLEY ❑Dewatering 0 Irrigation ❑Test Well 0 Other _ ___ Well Street Address 8159 NE BELFAIR TAHUYA RD Construction Type: Method: l!J New well ❑Alteration D Driven ❑Jetted 0 Cable Tool City TAHUYA County MASON O Deepening 0 Other ❑Dug !l Air- 0 Mud-Rotary Tax Parcel No. 322027600500 Dimensions: Diameter of boring 6 in..to 163 ft. Was a variance approved for this well? a D Yes O No Depth of completed well 163 ft _Construcdon Details: Wall '?If yes,what was the variance for Casing Liner Diameter From To Thickness Steel PVC Welded Thread I 1 I ❑ 6 in. +1 158 .250 in. p I 0 ❑ I 0 Location(see instructions on page 2): 0 WWM or 0 EWM ❑ i 0 in. _ _ in. ❑ I ❑ G 1 ❑ NW 1/4--14 of the SE %;Section 2 Township 22N Range 3 ❑ I ❑ in. _ _ in. ❑ I ❑ DID ❑ I 0 in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345)47.41974 _ Longitude(Example:-120.12345) -12301624 Perforations: ❑Yes A 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 ft.below round surface Formation:Describe by color,character,size of material and structure,and the kind and nature of thc material in each layer penetrated,with at least one entry for each change of Screens: Al Yes D No B K-Packer b Depth ft. information. Use additional sheets if necessary. Manufacturer's Name_ Material From To Type STANLESS Model No. Diameter 6 in. Slot size 10 in.from 158 ft.to 163 ft. CLAY 8r GRAVEL BROWN 0 154 Diameter in. Slot size in.from ft.to ft. GRAVEL H2O BROWN 154 — 163 Sand/Filter pack:0 Yes L9 No Size of pack material in. Materials placed from ft.to R Surface Seal: al Yes 0 No To what depth'? 20 R Material used in seal BENTONITE ' Did any strata contain unusable water? ❑Yes M No Type of water? Depth of strata Method of sealing strata off Plump: Manufacturer's Name GOULDS Type: SUB ---- H.P.2 Pump intake depth: 15m ft. Designed flow rate: 10 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing 1 ft.above ground surface ___ Static water level 108 R.below top of well casing Date 9-22-22 Artesian pressure lbs.per square inch Date _ Artesian water is controlled by ______ (cap,valve.etc.) Well Tests: Was a pumping test performed? ❑No l Yes by whom? Yield 18 gpm with31 ft.drawdown after 4 hrs. Yield gpm with ft.drawdown after hrs. ___ Yield gpm with_R.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 gpm with stem set at ft.for hrs. Date Artesian flow gpm Temperature of water "F Was a chemical analysis made? 0 Yes LI No Start Date 9-9-22 Completed Date 9-17-22 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 Cal Trainee 0 PE-�Print tNName MADI TROTTER Drilling Company COOLWATER DRILLING,INC. Signature �. - "' Address 10921 NW HOLLY RD License No.3367 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License N Contractor's Sponsor's Signature "-------- J T �r_— Date 10-5 22 Registration No.COOLWD1941QM ECY 050-1-20(Rev t 1/18) 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 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6 341. 26276 Twelve • Trees Ln NW Ste.0 a• ' SPECTRA Laboratories- Kitsap Pouisbo,WA 98370 —Where experience mailers (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County f Collected rj Montt Day Year J . J 'M Type of Water System(check only one box) ❑Group A ❑Group B gooier Group A and Group 8 Systems-Provide from Water Facilities Inventory(WFI): IDJF • System Name: Contact Person: e00 i£ - Day : 3 330- o Cell Phone: Email: Eve.Phone: Send results to:(Print fug nave,add/ress�s and zip code a email above for electronic copy of mutts) coot �.aJ it fSL 6 fl.,L t. ri" tirr HAIL c&_ _ SAMPLE INFORMATION Sample collected by(name): Specific location where sample collected: Special instructions or comments: i Gt_ f=AB,L rp It v y fig Type of Sample(check only one box) 1.❑Routine Distribution Sample(Alp) 2.❑ Repeat Sample(A)?) Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine) Unsatisfactory routine lab number: Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: IS I I I I Chlorinated:Yes _.No El Triggered(AIP) Chlorine Residual:Total Free ❑Assessment(AIP) 4.Surface or GWI Raw Source Water Sample(Eku merabon) I S I I ❑ E.coil ❑Fecal Mend Yos No 5.i2L,Sa TrpleCoaected for Information Only. USE ONLY DRINKING WATER RESULTS . LAB SE ONLY atisfactory Total Coliform and 15 w_L l- Satisfactory ❑E.cof present col absent 1'eca�w la i> 9/1" -a a+^41;1{ Bacterial Density Results:Total Colifonn mpn/100m1.Ecof mpn/100m1 Fecal Coliform —cful100m1. HPC -_—cful1m1. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑.-----_ ..-- --.-_-_ Lab Reference Number 17123?Lei g10 —R 2-7 -Of Receipt Temp C': Method Code. SM9 ;/QT-COUNTI SM9222D Date In: Date Out: 11Weeatle load racy la M w of tee;emcnaconere to jI setae aleaddse e,eea Any w coming aQotlmue calm ter by re 1 CJ�.{J,/ /� �+}\ i[. �u.D4atwU/MDaderaeNd3G67)SS1H sd d (yam/�y eter en Mon Wee". DOH 010. m� 9-go These reMbretreah le To Woe Rion ara Pa ssnde(s)aa 010 marked rateaedy.T smon old net be reDrod,ced ersp) �(�� in aa.M 4 see are Woo lei bJ=P�aLeborteence 0014 ranp31319lSesee O&Mors -YhJ 2191207 MASON CO WA 11/30/2022 01:17 PM NOTCE ' GARY BOSLEY 9182262 Rao Fee: S294.59 Pages: 2 HillIIIAIII11bbIIVII1111 11IMIH IIII111111111111111111 _ _ Return To el Q :3ift Z-zc5 C fz.(t fit-- 51PR 1N65 )21 )E2si �-- ?yz s Grantor(s): (1) Gi4PY S . go S(,E', (2) Grantee(s): (1) PUBLIC / S,v� TZ Legal Description (1) '1 'r—!� Of' 6ory t_i 2-L/E 1 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) .a v 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: 1 9 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this '- ) day of /j01.)24,P/, 20 Z2" Signatu of Grantor(s): (1) g 6 (2) State of Washington County of Mason ) Page 1 of 2 1,the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 2.t day of tsio n1, , 20A01— , 6vA--) 4 g.75.IL, 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 da an y lash aOive writt . l} 3 NthAt. Notary Public in and for the State of Washington, residing(41 at o� o M,O�TA1tY � S � �sit My commission expires: 9 I Z�-( Page 2 of 2