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HomeMy WebLinkAboutWAT2023-00113 - WAT Application - 5/16/2023 �D��•t,,, WAT) L3 - CC I . `�°t MASON COUNTY R E C E V E D ..:" o; COMMUNITY SERVICES 4 Building,Planning,Environmental Health,Community Health MAY ! 23' Na'D�* 415 N 6th Street, Bldg 8,Shelton WA 98584, \A/ A r{ r reef Shelton:(360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 •:• Elmae(860)482-5269 bit 4B0 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: WAYNE MANN Date: ` ifre,7 ' '2 3 Mailing Address: 7605 19th LN SE Apt 101 Phone: 360-763-9830 Parcel Number: 12019-77-00050 Type of Water System Reason for Application _ ❑ Public/Community Water System (2 or more 0 Building permit t.h L 1 lc, 3 `Lk-O 55( connections) 0 Division of land: O Individual water source(one connection), #of Parcels? SPL O Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) Const.Financirtc ❑ 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. ❑ 1 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 j Individual Water Well El Water well report(attached to application). Depth 200 ft. 0 0 Well capacity Test(attached to application) 30 gpm 7 30 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. O Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.usiplanninq 14 'i5n 16fl 221 Water use or limitation recorded N/A L—I Yes l.( Well Drilled Date C (l�(2,Z Individual Spring/Surface Water O 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. 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: r Environ. Health: Date (Z�I Z� 2 of 2 CSD Director: Date or: • WATER WELL REPORT DEPARTMEN1 OF Notice of Intent No_ WE47288 ECOLOGY Unique Ecology Well ID Tag No. BNV852 Type of Work: 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: l!l Domestic El Industrial 0 Municipal Property Owner Name Wayne and Denise Mann ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 784E Point Wilson Rd Construction Type: Method: El New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason ❑Deepening ❑Other ❑Dug �Air- ❑Mud-Rotary fax Parcel No. 12019-77-00050 Dimensions: Diameter of boring 6 in.,to 200 ft Was a variance approved for this well? ❑Yes ❑a No Depth of completed well 200 ft If yes,what was the variance for? Construction Details: Wall Cuing Liner Diameter From To Thickness Steel PVC Welded Thread 0 I ❑ 8 in. 0 198 .025 in 0 I 0 O I 0 Location(see instructions on page 2): 0 WWM or 0 EWM D I ❑ in. in O I ❑ ❑ I ❑ NE h-y.of the SE V.;Section 19 Township 20N Range 1W DID in. _ in. ❑ I ❑ DID ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.205351 N Longitude(Example:-120.12345) -122.846694 W Perforations: ❑Ycs lia No Type of perforator used No.of perforations Size of perforations in.by in Driller's Log/Construction or Decommission Procedure Perforated from R.to It below ground surface Formation:Describe by color,character,size of material and stricture,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ©Yes 0 No K-Packer Depth 194 ft information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Type Wire Wrapped Model No. Material From To Diameter 5" Slot size.014 in.from 195 R.to 200 R. Brown silt,hard,dry 0 3 Diameter Slot size in.from R.to ft. Brown fine sand,clean,dry 3 33 Sand/Filter pack:❑Yes ll No Size of pack material ;,, Brown gravelly fine sand,silt binding,tight,dry 33 42 Materials placed from ft.to R. Brown medium clean sand,packed,dry 42 94 Brown fine to medium sand,packed,dry 94 163 Surface Seal: O Yes ❑No To what depth? 20 ft. Brown gravelly medium sand,moist,loose 163 178 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Ycs El No Brown gravelly medium sand,active,water 178 192 Type of water? Depth of strata Brown coarse sandy gravel,tight,water 192 200 Method of scaling strata off Pump: Manufacturer's Name Type: D.P. Pump intake depth:—ft Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 145_ ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 119 ft.below top of well casing Date 9/12/22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? El No 0 Yes r' > by whom? Yield gpm with ft drawdown after hrs. Yield gpm with R.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 Time Water Level Date of pumping test Railer test gpm with R.drawdown after hrs. Air test 30 gpm with stem set at 180 R.for 1 hrs. — Date 9/12/22 Artesian flow gpm Temperature of water 51 "F Was a chemical analysis made? 0 Yes 1C No Start Date 9/9/22 Completed Date 9/12/22 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 0 Driller 0 Trainee❑PE— t Na Rogeray Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 9/12/22 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 call 877-833-6341. • J 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com _nerd maims Optl.,; (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 9 I 20 I 22 4 15 (0 AU Mason With Dsy Year - WPM Mo Type of Water System(check only one box) 0 Group A ❑Group 0 DOther Group A and Group 0 Systems-Provide from Water Facilities Inventory(WFI): ID# System Name:Wayne Mann Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-426-395 1 Cell Phone: — Email: arleta@arcadiaddlling.com t} Eve.Phone: Send results to:(Print fell name,address and zip code cre-mail) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):max Specific location where sample collected: Special instructions or comments: Well Head#BNV852 784 E Point Wilson Rd,Shelton Type of Sample(check only one box) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes❑ No❑ 0 Distribution System Chlorine Residual:Total Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample _— _ ISI I I Unsatisfactory routine collect date: J l I_ ❑Triggered Chlorinated:Yes ElNo El ❑Assessment Chlorine ResIdual:Total Free 4. Enumeration Scr.rce water Sample IS I 1 I ❑E.col/ ['Fecal-Somas.,GNO,Sprints:Fumed Yes❑ No❑ 5. I Sample Collected for Informeion Only LAB USE ONLY DRINKING WATER RESULTS LAB U ONLY ❑Unsatisfactory Total Cdifonn Present and 1 Isfactory ❑E.coli present 0 Ecoli absent I Replacement Sample Required: t 0 Sample too old(>30 hours) ❑TNTC ❑ _,__-. Bacterial Density Results:Total Coliform /100m1. E.colii.. /10(ml. Fecal Cohfo q 0ml. HPC //1 r . Lab ,7Gf Number ( ! � Date Qivg is.„ ..i.vo Method Code: Date and Trntincubatep/�� SM 9223 8 (_]l1/�t 1� Dale Analyzed: SEP Date Receded: 2 DOB Lab-Same/ lab Use Only: 225 (3 DCM Ft=IOW*ld«u..04110-via,need tri•;Wreaks.e.,edlmaew roust,w akk 525.0127(T1u1 i'rcol iip` Ili•are*ar k • 2©I ke.AYe.atwww.doo watvfypIFP,ru -• 2197217 MASON CO WA 05/17/2023 02:26 PM NOTCE WAYNE MANN *186931 Rec Fee: $204 50 Pa es 2 I{INII If i IN I I I I I 11111111 I I I I 111111111 uu i I I I I F I'MI I Return To %os tq t4 LA!!t: (a 1 91 WiN 98503 Grantor(s): (1) W '(N 6 Y Y ,UF-1 , (2) Grantee(s): (1) PUBLIC Legal Description (1) VAN N6 A-A of .5f SEc 19 %et-4120o 114.46 Ivy! (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) t 2 D t, 9 .-.7'1 - Q d O S O 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: t 4 Maximum Annual Average Gallons Per Day: 50 gallons Dated on this . - day of /11/4Y , 20 s. Signature o Grant (s): (1) ' l/t , (2) Stat of hingt ) County of Mas ) Page 1 of 2 I,the undersigned, a Notary Public in nd for the above named County and State, do hereby perky that on this I(0 day of , 2d2?j, , atifi . • ,(/(12Y) f pe sonally appeared before me,who is known to be signer�f the above instrument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day an ear last ab itten. Notary P lic c of Was ington, residing at My commission expires: /(1D(2-40/— 2-3. 46 YEN;titE ouzo Notary Public moron h n My Conan.Oars Now+rilcer 4,2023 • • Page 2 of 2