HomeMy WebLinkAboutWAT2023-00080 - WAT Application - 4/20/2023 •
.v,„.crr�yti WATo'2O0i 0 O
`°S\ MASON COUNTY
•111 . '1` COMMUNITY SERVICES
�` f�ECEIVED
v,�•"-�w-�^�4' Building,Planning,EnvironmentalHealth,CommunityHealth
415 N 6th Street, Bldg 8, Shelton WA 98584. A�pp(� 2 0
Shelton: (360)427-9670 ext 400 :• Belfair: (360) 275-4467 ext 400 :• Elma: (360)482-5765 ext 40P23
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.
T.NV1RONMENTAL
Part 1: Applicant/ Parcel Identification HEALTH
Name on Applicant: KIFER CONSTRUCTION LLC Date: 4/20/2023
Mailing Address: 441 WILDFLOWER LANE Phone: 360 807 4140
Parcel Number: 220193303020
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit lo`-'0903:5--CO al
connections) 0 Division of land:
Individual water source (one connection), #of Parcels? SPL
41 Well ❑ Boundary line adjustment
0 Spring/surface water 0 Other(explain)
0 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:
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 4/20/2023
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
Water well report (attached to application). Depth `42)9 ft.
ic Well capacity Test(attached to application) 3 O gpm 7 v 0 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.
Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 141 151—I 16I-1221
Water use or limitation recorded N/A = Yes I / '
F 1
Well Drilled ......... ... ........................... Date tom' Z/1
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
El 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 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
i 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: 1 r
Environ. Health: 1 Date (2( I Z-
CSD Director: Date 2.i 2
•
II Iry v r. /I'' ,
WATER WELL REPORT .(ib,, ,�-G� DEPARTMENT OF
e,.,, Notice of Intent No. WE45972 ..r_-
ECOLOGY
Unique Ecology Well ID Tag No. BMS085
Type of Work: State of Washington
1D Construction Site Well Name(if more than one well): •
0 Decommission ,--> Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use. IN Domestic 0 Industrial ❑Municipal Property Owner Name Michael Rule
❑Devatering 0 Irrigation ❑Test Well ❑Other
Construction T ype: Method: Well Street Address 441 E Wildflower Ln
O Nev well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other ❑Dug al Air- 0 Mud-Rotary Tax Parcel No. 22019-33-03020
Dimensions: Diameter of boring 6 in.,to 69 ft.
Depth of completed well 69 ft Was a variance approved for this well? 0 Yes 0 No
Comtructioo Details: wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
R I ❑ 6 in. 0 65 0.25 in. 3 I 0 O I 0 Location(see instructions on page 2): [WWM or❑EWM
❑ I 0 in. in. ❑ I ❑ ❑ I ❑ SW %-V of the NE V.;Section 19 Township 20N Range 2W
❑ I ❑ in. _ in. ❑ l ❑ DID
❑ I 0 in. _ _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.208528
Longitude(Example:-120.12345) 122.979322
Perforations: ❑Yes III No Type of perforator used
No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
Ptrforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and
nature of the material its each layer penetrated,with at least one entry for each change of
Screens: ❑Yes 0 No O K-Packer b Depth 63 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.016 in.from 64 ft.to 69 ft. Brown gravelly fine to medium sand,tight,dry 0 23
Diameter Slot size in front ft.to R. Black gravel with fine gray sand,silt bound, 23
tight,dry 41
Sand/Filter pack:0 Yes CI No Size of pack material in. Graysiltyclay,d soft
Materials placed from ft.to ft. dry. 41 49
Blue clay,stiff,dry 49 55
Surface Seal: El Yes 0 No To what depth? 20 ft. Black fine heavingsand with silt 55 58
Material used in seal Bentonite chips
Did any strata contain unusable water? 0 Yes E No
Black medium to coarse sand,heaving 58 69
Type of water? Depth of strata Gray sticky clay,dry 69 69
Method of sealing strata off
Pump: Manufacturer's Name Type:
tl.P. Pump intake depth:-ft. Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level 149 ft.
Stick-up of top of well casing 1 ft.above ground surface
Static water level 18 ft.below top of well casing Date 10/19/21
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test perfonned? +❑No 0 Yes T by whom?
Yield gpm with ft.drawdown after Ins.
Yield gpm with ft_drawdown after hrs.
Yield gpm with_ft.drawdown after his.
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 30 gpm with stem set at 40 ft.for 1 his. Date 10/19/21
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes ❑No Start Date 10/19/21 Completed Date 10/19/21
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 arc true to my best knowledge and belief
O Driller 0 Trainee 0 PE—Print Nam o Phythian Drilling Company Arcadia Drilling Inc.
Signature Address PO Box 1790
License No. 2053 .3v. City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License o. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 10/21/21
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 711 for Washington Relay Service. Persons with a speech disability can ca11877-833-6341.
vanguard Laboratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
yr►xelQAap 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sarni* County
06/13/2023 Cale a - AN Mason
Lionel Ley 'kW .��. ......._.•pm
Type of Water System(check only one box) - f
0 Group A 0 Group B ®Other `'v 1-
Group A and Group B Systems-Provide from 15 aler Facilites Inventory(W FI)
IDs --
System Name: Michael J. Rule
Contact Person.Arcadia Drilling.Inc
Day Phone:(360 )426-3395 Cell Phone (907 )205.7687
Ernad mkchael)rule57®gmail tom Eve Phone.( )
Send results to (P:i U name.aaVress atC r:p cc:e:r e-Ta)
■reraearcatt ne✓1{r corn AND s.:egarca1iw nitrn cc,
mithaellrule57 gntall corn
SAMPLE INFORMATION
samPle wieded by("me) Michael Rule
Speck Iocabon where sample cottected Special instructions or comments
hydrant _1
Type of Sample(select only one type of sample from types I through 5 below)
1 ❑Routine Distribution Sample(A/P) 2 0 Repeat Sample(A/P)
Chlorinated Yes.-. NO `0e^datnbutco syslern<ier cis rouene)
Unsatefadory=one lab number
Chlonne Residual Total—Free_
3 Ground Water Rule Source Sample frsabsfactory routine collect date
ISI f I-
Chiornated Yes No
❑Tnggered(A/P) Chbnne Residual Total Free
❑Assessment (A/P)
4 Surface or GW1 Raw Source Water Sample(Enumeration) I $ 1
❑E co* ❑Fecal Fargo Yet NO
5 jg Sample Cdeart to Intimation Only:
LAB uSE ONLY DRINKING WATER RESULTS tAB USE ONLY
❑Unsatisfactory Total Cot:fomt Present and ®Satisfactory
❑E cos present ❑E coil absent
Bacterial Density Results Total Colifonn /100m1 E colt /100m1.
Fecal Coiifeorm 1100m1. HPC /1 ml
Replacement Sample Required: 0 TNTC ❑Sample too old
❑ Sample Volume 0 Damaged Container 0
Cateilnne Reeved lab Rsfasnce Number
6j14412.3 1(i:20 , NI23014-10
PPcerpl Temp C. Metod Code
SM 9223$
Date Repone1 a DOH tab Use Only
DOH Lab-Sarrc'ee
285-&I4 10
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2196348 MASON CO WA
04/25/2023 11.12 AM NOTCE
RULE #186238 Rec Fee. $204 50 `Pa es. 2
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Grantor(s):(1) AA4c►r c—J tS c.t tr' , (2) RL1\) 4 5 . u(_-C
Grantee(s): (1) PUBLIC
Legal Description (1) N1.42 SE SW NE S 1C>t i--zz Q-Z
(Ab form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: 0 1 9 . 3 3 _ 0 3 0 2 0
TITLE NOTZFI O F WATER RESOURCE INVENTORY AREA(WRIA)
I (We), the un lgned an or(s), hereby place this notice on record that the described real
estate situa ed ason ounty, State of Washington is subject to water use restrictions and
conditions�• v _ gton State Senate Bill 6091 and Mason County Code 6.68. These
restrict s a • •••loons are based on location of property and/or Water Resource
Inventoiq a or WRIA.
Annual Average Gallons Per Day: 950 gallons
D, , on this 2 day of l?R Li_ , 207 i.
fgnature of G r
(1) iez,����' , (2) 1:3A-,4n.12e, J _ 4 n ,
State of Washington )
NNy County of Mason )
Page 1 of 2
I, the undersigned, a Nary Pub li n and for the above nand State, do hereby
certify tha�th`i_s S da of a vt.; , 20•
M`rY� A 14���..� � t,personally appeared ore me, who is known to be
signer of the above instrument, and acknowledged that ) (they) signed it.
GIVEN under my hand and official seal the day a ve writt
11\11114t111!//��
c7 a in and‘otate of Washington,
0 2 zko;;<< residi ! at }
1ARY N? _ mission expires: l -f— Q l
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2196348 Page 2 of 2 04/25/2023 11:12:05 AM Mason County, WA