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Home My WebLink AboutWAT2023-00121 - WAT Application - 5/30/2023 r — WAT 20Z3 - GG 1 Z ,c f PI-t \, MASON COUNTY RECEIVED „ z; COMMUNITY SERVICES (%s,.,f „v Building,Planning,Environmental Health,Community Health MAY 3 0 2023 n;f`�N 415 N 6th Street, Bldg 8,Shelton WA 98584, W �Ider Street Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)48 9 ext'4 FAX(360)427-7787 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: caie,w, So halt kG 1/ Date: 5/Z'`/ 72- Mailing Address: 161 G Frey A-c v'j, swill*,Phone: 340 - OP - /o q- t7 Parcel Number: 1 Z06/- qv - $9660 Type of Water System Reason for Application Public/Community Water System (2 or more Building permit 61 ZO 25 - CD Co 0 3 connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL 0 Well 0 Boundary line adjustment 0 Spring/surface water 0 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 j Name of Water System: N//i Weil,L 2l S - 0064 Water Facility Inventory(WFI) Number: n OVLQ j ,j-(p (write"none"for two-party) "Kr I am the manager of this vjater 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 nd local regulation. Signature of Water System Manager ` � Date 51 /7/5 This form may be scanned and available for public view at www.co.mason.wa.us. J, 1:11 I onn llriukin_-A\,ltor Re%ised 12S2018 Individual Water Well Water well report (attached to application). Depth ft. Well capacity Test(attached to application) !N07 gpm 7S UD 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). 'It Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14f 15(-11t 122n Water use or limitation recorded N/A 0 Yes Well Drilled Date \\. `Z� �`8 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: 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. 4 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). �Rev"iewer's Signatures: 60 Environ. Health: D YV t Date (Z -//1Z 2 of CSD Director: Date • WATER WELL REPORT DEPARTMENT Of Notice of Intent No. WE3 0 L.'AN V 4 Lull e.. ECOLOGY Unique Ecology Well ID Tag No. BKR182 Type of Work: State of Washington Site Well Name(if more th ti yse,11) vmoicew Vi East ❑a Construction 0 Decommission b Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: CC Domestic 0 Industrial 0 Municipal Property Owner Name Geoffrey Farrington 0 Dewatering 0 Irrigation Cl Test Well 0 Other Well Street Address Island Lake Construction Type: Method: City Shelton County Mason E New well 0 Alteration 0 Driven 0 Jetted CI Cable Tool C Deepening 0 Other 0 Dug Cl Air- 0 Mud-Rotary Tax Parcel No. 42001-40-00000 Dimensions: Diameter of boring 6 in.,to 77 ft. Was a variance approved for this well? 0 Yes 0 No ' Depth of completed well 75 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I 0 6 in. +1_5 71 .250 in. 'C I ❑ O I 0 Location(see instructions on page 2): IA WWM or 0 EWM O I 0 in. _ _ in• ❑ 1 ❑ DID NE ''/-%of the SE '/,Section 1 Township 20N Range 4W ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ o I 0 in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.260931 Longitude(Example:-120.12345) -123.103997 Perforations: 0 Yes W No Type of perforator used No.of perforations Size of perforationsD in. riller's Log/Construction or Decommission Procedure by in. 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: ❑a Yes 0 No E K.-Packer b Depth 69 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type stainless Slotted Model No. Brown silty sand,gravel,cobbles,loose 0 12 Diameter 5" Slot size.018 in.from 7 ft.to 75 ft. 12 19 Diameter Slot size_in.from ft.to ft. Brown silty sand,gravel,loose Brown coarse sand,gravel,loose 19 33 Sand/Filter pack:0 Yes E7 No Size of pack material in. Fine brown sand,gravel,loose,wet 33 47 Materials placed from ft.to ft. Small to medium gravel,coarse brown sand,wet 47 55• Surface Seal: E Yes 0 No To what depth? 19 ft. Black coarse sand,gravel,loose,water 55 75 Material used in seal Bentonite Chips Black medium sand,gravel,wet 75 77 Did any strata contain unusable water? 0 Yes El No Type of water? Depth of strata Method of scaling strata off Pump: Manufacturer's Name Type: — H.P._. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 242 ft. Stick-up of top of well casing +1.5 It above ground surface Static water level 33 ft.below top of well casing Date 11/26/2011 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) • Well Tests: Was a pumping test performed? E]No 0 Yes by whom? Yield gpm with ft.drawdown after hrs. Yield . gpm with ft.drawdown after hrs. Yield_gpm with_tt.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 Tim,, Water Level Date of pumping test Bailer test gpm with ft.drawdown after hrs. Air test 20 gpm with stem set at 60 R for 1 hrs. Date'11/26/2018 -- Artesian flow gpm Temperature of water 48 °F Was a chemical analysis made? 0 Yea E No Start Date 11/26/2018 Completed Date 11/26/2018 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 0 Trainee 0 PE—Print N sh Koepp Drilling Company Arcadia Drilling Inc. Signature r Address PO Box 1790 License No. 2874 f City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License . Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 11126/2018 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6871. Printed F ro„tisofls yl(tjt,�tgfc5 tis cccajl,��l f¢ Itt�t'lyn8�on, lei' mice. Persons with a speech disability can call 877-833-634I. • Printed Printed� from l/IMason jCounty (D�MuS{ (Y („J1V� Thurston County Environmental Health 2000 Lakeridge Dr.SW !Olympia,WA 98502 ,.._• 360 867-2631 COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected (a � (D1 '23 : vp titSi,�'1 Pm Mont, Day Year Type of Water System(check only one box) 0 Private Household 0 Group A 0 Group B ,tt0ther Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: SL{/$IY! 5G(0.4*.8( Day Phone:(73( )) -10 - Cell Phone:( ) E-mail: 6„,444,.ci cf rAii.6oivt Eve.Phone:( ) Send results to:(Print full name,address and-and vp code or email address) SAMPLE INFORMATION Sample collected by(name): • Specific location or address where sample collected: Special instructions or comments: ,140 Tim ,f wA Type of Sample(must check only one box of#1 through#4 listed below) 1.XRoutine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total_Free_ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total_Free_ ❑E.coil-GWR(A/P) ❑Fecal-surface.Owl.sings(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(AR) Unsatisfactory routine collect date: ❑other 1 1 S 4.0 Sample Collected for Information Only Investigative.._ Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and ►` atisfactory 0 E.coli present ❑E.coli absent o orm detected Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform 1100m1. E.coli 1100m1. ,ecal Coliform 1100m1 Enterococci 1100 ml. .rod Code::M 9223E OSM 9222D Date and Time Received: WI- ❑SM 921 B ❑Entt�eefrolert® to'(.0Z� 1 h C) Date and Time Analyzed: 6-- v` 23 Date Reported&- Sample Number(DOH number plus tse digits) Lab Use Only: IMEMEW bL.D Rba3 - 00(QO- - � 2197772 MASON CO WA 06/01/2023 11:06 AM NOTCE 11� N IIII II I Fee. I I I II11 I1I IIIIIIII1INIVIIINIIIIC1IIIIII I Return To RECEIVED Sa/ c‘a,,.A__.r ENVIRpN ENTAL /4, ( e F•-o2 /9c,-(s HEALTH SUN - 1 2023 5h -/7ah, IA)* ? 615 W. Alder Street Grantor(s): (1) ✓a /-efr" Sit ak1A€ l , (2) Grantee(s): (1) PUBLIC Legal Description (1) L_Dt Is '3P 4. 3 1 2-I (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 44 , p9, 0 0 1 - `- v- 1 O v GP 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: IL-4 Maximum Annual Average Gallons Per Day: q J� gallons Dated on this 3 I day of /4 Q r , 20 2-3 Signature of Grantor(s): (1) C/� 5 , (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public i and for the above named County and State, do hereby c_ ify that on this 2-D1 S' day of , 20R_ , Qf?y(\ Vic, Kfi per onally 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 a year last above written. C ill 47 Note Public in and for the Stat f Washington, 1 4 KIM M ALBAUGH residing at ,C) .- U , Notary Public State of Washington My commission expires: ~IS"c 5 License Number 39387 My Commission Expires February 15, 2025 • Page 2 of 2