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HomeMy WebLinkAboutWAT2023-00079 - WAT Application - 4/20/2023 • M, R 2 4 2'323 Street WAT o�Da-�� 0007 l �1��N deter ENVIRONMENTAL 415 N.6th Street MASON COUNTY Shelton,WA 98584 . ) COMMUNITY SERVICES HEALTH Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,Community Health 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 Name on Applicant: dextr1c WanSovx Date: LillolaQ- Mailing Address: Jio ►-; by Phone: Zob 4CA,,'b�iloto Parcel Number: a DOIOU Type of Water System Reason for Application ❑ Public/Community Water System (2 or more d Building permit OLD7Oa3_0Oy al(ig connections) 0 Division of land: ��ii Di Individualwater source (one connection), #of Parcels? SPL 11 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) 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. ❑ 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:\EH Forms\Drinking Water Revised 427,2021 Individual Water Well 76, Water well report(attached to application). Depth 7017 ft. `❑/Well capacity Test (attached to application) 6 gpm -7 Od°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/planninq 14 X 15_ 16 22_ Water use or limitation recorded N/A Yes'\ Well Drilled Date 9 i 1 0 o a3 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. 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). �R^eviewer's Signatures: Co Environ. Health: `►' I Date (Z-s f-u- This form may be scanned and available for public view at www.co.mason.wa.us. Page 2or2 .4111111111111111.1.6 S_eN LI B 8b.0a073 -oa R(0`' 2 0 2C2 ENVIRONMENTAL 615 W. ^' '< r Street HEALTH WATER WELL REPORT ;kw DEPARTMENT OF Notice of Intent No. WE48998 • ECOLOGY unique Ecology Well ID Tag No. BNV855 Type etWeric State of Washington 0 Construction Site Well Name(if more than one well): 0 Decommission I Original installation NOI No. Water Right Permit/Certificate No. Preposed Use: a Domestic 0 Industrial 0 Municipal Ply Owner Name Jennifer Hanson ❑Dewatumg 0 Irrigation 0 Test Well ❑Other Well Street Address 161 E Meriot Ln Camtr.cfio.7ype: Method: El New well ❑Alteration 0 Driven ❑Jetted 0 Cable Toot City Shelton County Mason ❑Deepening ❑Other 0 Dug RI Air- ❑Mud-Rotary Tax Parcel No. 22025-79-00100 Di eneions: Diameter of boring 6 in.,to 280 fL Depth of completed well 273 ft. Was a variance approved for this well? ❑Yes 0' No Constructing Details: Wall If yes what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread (P I 0 8 ice. 0 288 .025 is ® I 0 IN I 0 Location(see instructions on page 2): 3 WWM or 0 EWM ❑ I 0 `i. ❑ 1 ❑ ❑ I ❑ SW Y Y.of the NE Y.;Section 25 Township 20N Range 2W❑ r-cr _ . in in. ❑ I ❑ 0 I 0 ❑ I O in. is ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.192961 N Longitude(Example:-120.12345) -122.873437 W Perforations 0 Yes O No Type of perforator mod No ofperforations Size ofperfaatiom is by in. Driiler's Log/Construction or Decommission Procedure Perfttated from 8.to R below ground surface Fo®ation:Deaatbe by color,character,size of material and structure.and the kind and — nature of the material in each layer penetrated,with at least can entry for each change of Seem: ®Yea 0 No P1 K-Packer b Depth 262 & information. Use additional sheets if necessary. Manufacturers Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Diameter 5' Slot size.014 in.hem 268 g.to 273 IL Brown pea gravity fine sand,loose,dry 0 9 Diameter Slot size in teat f1 to ft. Brown gravelly fine sandy sat,tight,dry 9 53 Seed/Filter pack❑Yes ®No Sae of peck material in. Grimy brown medium sand,loose,dry 53 113 Materials planed from t3 to ft. Brown fine sandy silt,tight,dry 113 206 Surface Seal: p Yes 0 No To what depth? 20 ft_ Brown fine sandy gray silt,tight,dry 206 215 Ma isl used in seal medium sand,heaving 215 253 Did any strata centaur unusable water? ❑Yes ©No Grady coarse sand,brown,active,water 253 263 Type of water? Depth of strata Brown day,stiff,dry 263 264 Method or sealing strata off Brown coarse sandy gravel,water,heaving 264 280 Pump: Manufacturer's Name Type: HP. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sa level 237 ft Stick-op of top of well casing 1 &above ground surface Static water level 197 ft below top of well casing Date 9/6/22 Artesisn 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 b by whom? Yield gpm with ft.drawdown alter hrs Yield gpm with ft.drawdown afar hrs. Yield gpm with R drawdown after her Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Tame Water Level Time Water Ravel Time Wakes Level Date of pumping test Bailer test gpm with f ddawdown after bra. Air test 15 gpm with stem set at 260 R.for 1_IS. Ike 9/6/22 Artesian flow_gpm Temperature of water 51 °F Was a chemical analysis made? ❑Yes E No Start Date 9/6/22 Completed Date 9/7/22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well constntction standards.Materials used and the information reported above are true to my best knowledge and belief E Driller 0 Trainee 0 PE—Print N y Phythian Drilling Company Arcade 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 9/7/22 ECY 050-1-20(Rev 09/18) If you need this document in an alternate fonnat,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. 5L-D 9 -o04-240 1786 SE Mile Hill Drive lI Port w.Orchard,WA 9836comb R E C E I` ' D ` SPECTRA Laboratories-Kitsap www.spectra-lab.com v ,...pt.r..'.eau,. (360)443-7845 COLI FORM BACTERIA ANALYSIS FORM JUN 1 2023 Date Sample Collected Time Sample County Collected 615 W. Alder Street 9 / 30 / 22 mud Mason hkalel Ory Yea 2 : o0 DPAI Type of Water System(check only one box) ❑Group A ❑Group B nOther Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name:Jennifer Hanson-161 E Merlot Lane,Shelton Contact Person:Arleta Eisele/Arcadia Drilling Day Phone: 360-426-3395 Cell Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send results to:(Print lull name,address and zip cede or e-mal) arletat arcadiadrilIing.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name): Max Specific location where sample collected: Special instructions or comments: BNV855 Type of Sample(check only one box) 1. Routine Distribution Sample 2.Repeat Sample(after unsaL routine) Chlorinated:Yes El No❑ ❑Distribution System Chlorine Residual:Total_Free_ Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample _ S I I 1 Unsatisfactory routine collect date: ❑Triggered Chlorinated:Yes ElNo❑ ❑Assessment Chlorine Residual:Total_Free 4. Enumeration Source Water Sample IS I I ❑E.coil ['Fecal-seam,Gtiv1,sp-ga:Fiived vas No 5.0 Semp%Collected tor Information Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Conform Present and 5,3CSatIsfactory ❑E.coli present 0 Ecoli absent Replacement Sample Required: 0 Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform___ ./100ml. E.crofl. /t00ml. Fecal Coliform 1100ml. HPC _ /1 ml. Lab lDNumber Date andistr ssJ xrn is35 Method Code: Date and Tmlpipotrp9 ryt� SM 9223 B xj'J i1 lUL Date Analyzed: OCT J 2022 Date Reported: OCT 3 2022 DOH Lab-Sam Lab Use Only. 225 • 0I- 0 loin ima11301J19(AM.dn 04/1 • you aaad linpacikov n in'am turret aea a00.S25,0121(1DQ'Rr.1714 TNa and*Ai pu0W5in N nth* agcld lee a.'m. 61,V,VR3--04/R 2195685 MASON CO WA 04/06120 23 03:4 9 PM NOTCE , W a�eS 2 1111II�11UIIuMJIIIIIyIN 1110111p11111f R eturn To Vi vini�ey 119y1Son 1*0 V LAP gahw24-2e1too cialsw+ tV E NV/RQNAINT APR 2 0 2023 H EA ,._ �L C l H 615 W. Alder Street Grantor(s): (1) enrLe.1- anwn , (2) Ddu lac t�2-r►sOrl Grantee(s): (1) PUBLIC �J Legal Description (1) TR 10 OF SURVEY VOL 3 PG 150 (Abbreviated form:l.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 2 2 0 2 5 - 7 9 - 0 0 1 0 0 S - 7ao R� 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: 14 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this if) day of April , 20 Signature of Grantor ): (1) )1U1D , (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a otary Pub• in and for the above named County and State, do hereby certify that on this day o 203 , -\Nv�k.k% nSol- enn't )-lansc -) 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 d year last above written. c' ..... Notary ublic in and Tdr the State of Washington, i • NpTgRy ..L, residing at Cep--)4r—aJ2a,_ Lv A 01 PtJBL C its rf My commission expires: 3I i to I Do y�F WAS .+„• Page 2 of 2