HomeMy WebLinkAboutWAT2023-00055 - WAT Application - 3/9/2023 WAT 2023 - 0005Gj
, Z MASON COUNTY
COMMUNITY SERVICES
i RECEIVED
Building,Planning,Environmental Heslth,Community Heahh
415 N 6th Street,Bldg 8,Shelton WA 98584, 0 9 2023
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 NM
FAX(360)427-7787
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 Identification
Name on Applicant: Christopher Gaynor Date: 0 3/68/Z3
Mailing Address: 1500 E Mason Lake Rd Shelton Phone:360-990-2881
Parcel Number: 32134-23-90020
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit-blel j. 6021 L.'
connections) 0 Division of land:
O Individual water source (one connection), #of Parcels? SPL
El Well 0 Boundary line adjustment
0 Spring/surface water❑ 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)
❑ 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
XWater well report(attached to application). Depth ( (D ft.
p( Well capacity Test (attached to application) Z5 gpm � QO 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.
XI Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14I] 15U 16(_1220
Water use or limitation recorded N/A Yesr 7ci r1Ff 21qYbg5
5
Well Drilled Date /j /7073
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)
;t( 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: /7
Environ. Health: Date 6 26/ 70 7j
2 of
CSD Director:
Date
WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE52836 •
ECO LOGY Unique Ecology Well ID Tag No. BNH 874
Type of Work: State of Washington
E Construction Site Well Name(if more than one well):
❑ Decommission rs Original installation NOI No. Water Right Permit/Certificate No. •
•
Proposed Use: ❑' Domestic 0 Industrial 0 Municipal Property Owner Name Chris Gaylor '
0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 1500 E Mason Lake Rd
Construction Type: Method:
❑New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other 0 Dug M Air- ❑Mud-Rotary Tax Parcel No. 32 1 34-2 3-90020
Dimensions: Diameter of boring 6 in.,to 110 ft. Was a variance approved for this well? 0 Yes E No
Depth of completed well 110 ft.
if yes,what was the variance for?
Construction Details: Wall •
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
O I ❑ 6 in. +1 105 .25 in. O I ❑ ❑ I ❑ Location(see instructions on page 2): O WWM or 0 EWM
❑ I ❑ in. _ _ _in. ❑ I ❑ ❑ I ❑ SW 'Y.-'/of the NW '/;Section 34 Township 21N Range 03
❑ I 0 in. _ _ in. ❑ I 0 El I ❑
❑ I 0 in. _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345)
Longitude(Example:-120.12345)
Perforations: 0 Yes OO No Type of perforator used Driller's Log/Construction or Decommission Procedure
No.of perforations Size of perforations—in.by in Formation:Descnbe 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: 1 Yes ❑No O K-Packer > Depth 104 ft. information. Use additional sheets if necessary. '
Manufacturer's Name Johnson Material From To
Type Stainless Steel Model No. 0 1
Diameter 5 in Slot size .016 in.from 105 ft.to 110 ft. Top soil
Diameter in. Slot size in.from ft.to ft. Sand,gravel,silt,brown/hard 1 23
Sand,silt,some gravel,brown/hard 23 50
Sand/Filter pack:❑Yes O No Size of pack material in. Sand,silt,more gravel,brown/hard 50 55
Materials placed from ft.to_ft.
Sand,gravel,silt,brown/soft,wb 55 63
Surface Seal: O Yes 0 No To what depth? 18 ft. Sand,little water,brown/soft 63 73
Material used in seal Bentonite Granular Sand,gravel,silt,brown/hard 73 78
Did any strata contain unusable water? ❑Yes O No Clay,gray/hard 78 82
Type of water? Depth of strata ——.
Method of sealing strata off Sand,fine,gray/hard,wb not screenable 82 94
Sand,silt,gray/hard,little gravel,wood,eb 94 110
Pump: Manufacturer's Name N/A Type: Clay,gra/hard 110
H.P.— Pump intake depth:—ft. Designed flow rate: 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 42 ft.below top of well casing Dale 5/26/2023
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? O No ❑Yes => by whom?
Yield—gpm with_ft.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 from well �151
top to water level) `�L�
Time Water Level Time Water level Time Water level
Date of pumping test — — RECEIVED
Bailer test gpm with_ft.drawdown after_hrs. ,
Air test 25 gpm with stem set at 109 ft.for 1 hrs. Date 5/26/2023
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes O No Start Date 5/26/2023 Completed Date 5/26/2023
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 0 Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature C, -11!'..../t1 Address 1162 NW State Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
iF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 5/30/2023
ECY 050-1-20(Rev 1 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
877-833-6341.
a
2194685 MASON CO WA
Return To 03/09/2023 11:29 AM NOTCE
Chh5 4-o ()he ' °e} INllllf{IlllIIIIIIIIIIiii�I IlllllLII[IIi11111IIIIIIIIIIIPages:
I[I Illl'►IIIJIII
Itioo E mwswt,L P ( "d—
Grantor(s): (1) cen.1`ophe.r (2)
Grantor(s): (1) PUBLIC
Legal Description (1) Lth 2- 314aAFa*Z18(-1/6Th'n 6tc)rtu) 5 37/6,3477,-1(/55
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 1 3 LI a 3 - �l 0 0 2-- 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: C�(] gallons
Dated on this c4 day of /tweC.N , 20 Z3.
Signatureof Grantor(s):
ei,4_(1) _ , (2)
State of Washington
County of Mason )
Page 1 of 2
I
4
4
1, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this q day of Yna-t c , 20 2� ,
CSC;S3o?1(k.e( Gay ylo 2 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 ear last above written.
, 7a3L0
Notary Public No ary Publics in and for the ate Washington,
State of Washington
ARIANE M PAYSSE residing at /�'(y]��. n
1�-,311 �6
MY COMMISSION EXPIRES }'Z J2 Q
12/29/2025 My commission expires: f
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Page 2 of 2
(4- 111-111k.
Lewis County Environmental Health Laboratory
360 NW North Street Chehalis,WA 98532 TYPE OF SAMPLE(select only one type of sample from types 1 through 5 below)
(360)740.1237
COLIFORM BACTERIA ANALYSIS 1.❑Routine Distribution Sample(A/P) 2 ❑ Repeat Sample(AIP)
E Date Sample Collected Time Sample County Chlorinated:Yes No (from distribution system after unsat.routine)
d Collected Unsatisfactory routine lab number:
Z 1�. r� Chlorine Residual:Total Free
{� —'- Month Day Year 12-:t1, ,01->ti^q 3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
e Type of Water System(check only one box) r I S I I I / /
> 0 Group A ❑ LJ Group B Other t ❑Triggered(A/P) Chlorinated:Yes No
�_ '77) Group A and Group B Systems ❑Assessment(A/P) Chlorine Residual:Total Free
r--- —_ -
._- g System Name: w)4 i t,..1,) 1-1 r,i,, (Y , Y.,I 4.Surface or GWI Raw Source Water Sample (Enumeration)
I\ I D E.coil E Fecal Filtered Yes No ISI
Contact Person: „c�'e.Gv1 f 5. ple Collected for Information Only
( 1'1rY C.
` Day Phone 5 7y/ i Eve.Phone
`/�'IOW) ( ) LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
C Cell Phone( ) FAX( ) /
0 Unsatisfactory Total Coliform Present AND L`c, tisfactory
SAMPLE INFORMATION ❑E.coli present ❑E.coli absent �/11
f. • Sample Collected By(Name): __ �`, } Bacterial Density Results:Total Coliform /100m1. E.co/i /100m1.
,J3 Specific Location Where Sample' Special Instructions or Comments: Fecal Cdiform /100m1. HPC /1m1.
- 1.-`5 ' Collected(Address and Faucet):
.4111 16 (•�; E �11}a 041 Replacement Sample Required: ❑TNTC op Sample too old
t ,( �{C�//�� { `f 0 Sample Volume ❑Damaged Container ❑
a r 14. I•(1. Date/Time Received/Initials: . Date Analyz�Bd/Initlals,/
j / I
1`.` 1 I.0 n Receipt Temp C°: Method Code:( 23BM9221 B
d Date Reported to DOH: Lab Use Only: `-- .•-
DOH Lab-Sample#
DOH Fenn 0r301320(eFeciw 617)
i .
i
�— ''0 Lewis County Environmental Health Laboratory
7 360 NW North Street, Chehalis, WA 98532
( — (360)740-1237
LEwis COUNTY/ Nitrate
ajgripil=smiReport of Analysis
am
Date Collected: (MM/DD/YY) t / J Timer 'LJ). ;pm System Group Type: (circle one) A B C1chA PUT—
,
_
Water System ID Number: System Name: J rr f . r t.- I,,,,,A� .Y ,.
Lab Number/Sample Number: 091/ 7, r j , �'
P ( .- )r County:
Sample Address: (-5jte E, /v\(,-S�t-1 I,__c j R Source Number(s): (list all sources if blended or composited)
Sample Purpose: (check appropriate box) Time
[f / RC—Routine/Compliance(satisfies monitoring requirements) Date Received: (MM/DD/YY) / /
❑ C—Confirmation(confirmation of chemical result)*
❑ I—Investigative(does not satisfy monitoring requirements) Date Analyzed: (MM/DD/YY) lk / i C.1 / __ t
❑ O-Other(specify-does not satisfy monitoring requirements)
Date Reported: (MM/DD/YY) / /
COMMENTS:
Sam le Composition: (check appropriate box) Sample Type: (check one) 0 Pre-treatment/Untreated(Raw)
[S—Single Source ❑ Post-treatment(Finished)
❑ B—Blended(list source numbers in"Source Numbers"field) ❑ Unknown or Other
❑ C—Composite(list source numbers in"Source Numbers"field)
Sam le Collected by: i---^--
❑ D—Distribution Sample P (name) '
Phone Number: /,0- 71/( " 5.37
)
Send Report to:,� / ! Special Instructions or Comments:
•
! l ,IG( k kt- Ai AG! --)1;1,
r
A)\ 't";\to Av
r r rT .-
' ANALYTICAL RESULTS
DATA EXCEEDS
DOH ANALYTE QUALIFIER RESULTS SDRL TRIGGER MCL UNITS MCL? METHOD ANALYST
# (X if Yes) INITIALS
% Hach
0020 Nitrate-N ' ( '' 0.5 5.0 10.0 mg/L L
10206
NOTES:
*Confirmation: Include the original lab number,sample number,and collection date of original sample in comment section.
DATA QUALIFIER:A symbol or letter to denote additional information about the result.
EXCEEDS MCL(Maximum Contaminant Level): Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-291 WAC.
Please contact the department's drinking water regional office in your area to determine follow-up actions.
mg/L: milligrams per liter or parts per million.
SDRL(State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the department.
TRIGGER: The department's drinking water response level. Systems with contaminants detected at concentrations in excess of this level may be required
to take additional samples or monitor more frequently. Please contact the department's drinking water regional office in your area for further information.
-___— INTERPRETING NITRATE SAMPLE RESULTS FOR NON-PUBLIC WATER SYSTEMS
1
r Less than 0.5 mg/L(
(/ 0.5 mg/L): Water does not contain significant amounts of nitrates.
0.5-3.0 mg/L: Water in this category should be monitored regularly to determine if nitrate concentrations are increasing. We recommend yearly
testing.
3.1-9.9 mg/L: This water should be monitored at least yearly. Surface land use should be evaluated to determine if there are nitrate sources that can
be minimized or eliminated in order to prevent further contamination.
Greater than 10.0 mg/L(>10 mg/L): Some people,particularly infants and pregnant women,are considered to be at risk if they drink this water.
Additional information from the Washington State Department of Health is included.
More information is available at the following Washington State Department of I lealth websites:
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