HomeMy WebLinkAboutWAT2023-00096 - WAT Application - 5/2/2023 WAT 202A - 00{A6p
0415 N.6'h Street
MASON COUNTY Shelton,WA 98584
Shelton:360-427-9670,Ext.400
COMMUNITY DEVELOPMENT
Bclftir:360-275 4467,Ext.400
Permit Assistance Center,Building,Planning 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
04m7Ae. �Ii^.>1 ey
Name on Applicant: � F.;4ti,M ARIPu� 4(SULfl/.J Date: ,0/,�,02,3
Mailing Address: f D• VpX 429 /4yiu'r 9jV71.) Phone: (#60)4¢0-.470
Parcel Number: Z2i(4.7fj-- co/ 7/
Type of Water System Reason for Application
Public/Community Water System (2 or more X Building permit -bICl O -O01S
connections) ❑ Division of land:
❑ Individual water source (one connection), # of Parcels? SPL
O Well 0 Boundary line adjustment
O 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: 2~P4 via l-
Water Facility Inventory (WFI) Number: /S(GIE
(write "none" for two-party)
O I am the manager of this water system. The water system has been approved for 2 services.
There are presently ( connection(s) i use. This will be the 2-417 connection.
O I am the manager of this system. This connect n will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to ull time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provid water to this (these) connection(s)without exceeding
the limits of the water system or an limits set y st e and local regulation.
r
Signature of Water System Manager Date ,,0fre)23
This form may be scanned and available for public view at www.co.mason.wa.us.
J:'El1 Folinsi Drinking Water Revised 4/4/2018
sun
Individ al Water Well
J Water well report (attached to application). Depth HO ft.
Well capacity Test (attached to application) gpm ? �0O 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 141715 16 22
Water use or limitation recorded N/A Yes v hretr •
Well Drilled Date 1 I/7/zo Z Z
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 comp iance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements f Sanitary Code, Title 6, Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Addi ional Growth Management regArpta .`CJt 36.70A RCW. rr'1� ��
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended
M use,�th�lSll9
reason(s).
ASON COUNTY ENVIRnNMENTAL HEALTf'
Reviewer's Signatures: DJA
Environ. Health: Date -7/0770 Z3
/ '
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT Df rrA, h t N 'l' Notice of Intent No.WE48789
ECOLOGY Unique Ecology Well ID Tag No.BNA 197
Type of Work: Stare:v Washinetoc
g Construction Site Well Name(if more than one well): _
C 0.•commission ct. Original installation NOI No. Water Right Permit/Certificate No._
Proposed Use: T Donwsiic f.J Industrial 0 Municipal Ptupvity Owner Name Jan Oosterveld
❑Dewatenng :J Irrigation ❑Test Well Li Other__.________
Well Street Address Wilson Way___
Construction Type: Method:
I New well Alteration 0 Driven C Jetted E Cable Tool City Grapeviewr County Mason _
❑Deepening 0 Other ❑Dug G Air- C Mud-Kotaty Tax Parcel No. 221147690174
Dimensions: Diameter of boring 6 in.,to 140 ft, Was a variance approved for this well.r ❑Yes ❑No
Depth of completed well 140 ft.
Cwatrsetios Details: Wall— If yes,what was the variance for? _
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
❑ 6 in. +2 135 1!4 in. A i ❑ 7 i LI locution(sec instructions on page 2): O WWM or 0 EWM
O 1 0 in. in. ❑ I 0 ❑ ' 0 SW V.-'Vaofthe SE 'V.;Section 14 Township 21N Fan 2W
—_ b=
❑ 1 ❑ in. —_ —_ —_in. ❑ I ' ❑ 1 ❑' Latitude(Example:47.12345)
❑ 1 ❑ —in. — in. ❑ ( :3 0 1 CIP
Longitude(Example:-120.12345)
Perforations: 0 Yes I No Type of perforator used
No.of perforations Size of perforations_in.by_in Driller's Loy/Construction or Decommission Prxerur
Perforated from_ft.to ft.below ground surface Describe by color,character,size of material and structure.anti the land and
nature of the material in each layer penetrated,with at least one entry fie each change of
•
Screens: `!I Yes 0 No K-Packer b Depth 133 ft, information. Use additional sheets if necessary.
Manufacturer's Name Alloy Machine Works Material From To
Type Stainless Model No.
Diameter 5 in. Slot sire 14 in.from 135 ft.to 140 ft, Top Soil 0 3
Diameter in. Slot size in.front ft.to ft. Hardpan 3 20
7Yes 0No Size of Brown Gravel 20 40
Sand/Filter pack: puck material in.
Materials placed from_ft.to_ft. Blue Clay Silty Gravel 40 86
Orange Gravel/Clay 86_ 100
Surface Seal: I Yes 0 No To what depth?20 ft. Brown Gravel&Sand/water 1(Y0 140
Material used in seal bentonite —
Did any strata contain unusable water? 0 Yes N No •-- - -
-
3 Type o:'water? Depth of strata.___ ...
Method of scaling strata off
Pump: Manufacturer's Name orundlos Type:sub —'
H.P. 1/2 Pump intake depth:_ft. Designed flow rate:_gpm --
Water Levels: Land-surface elevation above mean sea level fl.
Stick-up of top of well casing ft.above ground surface
Static water level 102 II.below top of well casing Date
-
Artesian pressure lbs.per square inch Date
Artesian water is controlled by Icap,valve,etc.)
Well Tests:
Was a pumping test performed? C No 0 Yes c--' by whom?
—
Yield_gpm with ft,drawskrwn after hrs.
Yield_gpm with_It,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 -
Bailer teat 10 gpm with 28 ft.drawdown after.' hrs.�
Air test—gpm with stem set at ft.firr_hrs. Date 11/05/22
Artesian flow_spin
Temperature of water ''F Was a chemical analysis made? 7 Yes ®No Start Date 09/05/22 Completed Date 11/07/22—
WELL CONSTRUCTION CERTIFICATION: I constructed and'or accept responsibility for construction of this well,and its compliance with II W ashington well
• construction standards.Materials used and the information reported above are true to my best knowledge and belief.
l Driller 0 Trainee 0 PE-Print Name Jack Grande Drilling Company Davis Drilling
Signature t 4rae, Address 340 NE Davis Farm Rd
License No.258 City,State,Zip Bel(air,Wa,98528
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.DAVISDI I100A C tte l t/7/22
EC'Y 050-1-20(Rev 0S 14)Ij pwr need this.document in so alternate jur•mat,please call the Water Resources Program at 360.407-6ct?2.
Persons with hearing fuss can call 7I!/ie'Washington Relay Service. Persona with a speech disability can call N77-833-6341.
tl _
• 1786 SE Mae Hill Ij
r ----- —
Dr. _�! SPECTRA Laboratories - Kitsap
Port Orchard,WA
98366 Who..experience metiers
— _ COUFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tin Sample I County
Collected
ii ' 2 "22. v c/ vl/rt
Day YeaPM i �' 1I
Type of Water System(check only one box)
❑Group A ❑Group B Ott,ar_
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: n 1 ( } 150 r\
W aLj. .
Contact Person:
V \J
Day Phone:( ) Cell Phone:( )
Email:
Send results to:(Print fell name,address and bp code e-mail)
...._ _cA,\JJ.b,r.)., ..4__nA,...__@._ ......... ._q_i___:__ _ki..
d),_
SAMPLE INFORMATION
Sample collected by(name):
ja(.lam _ I
Specific location where sample collected' Special Instrur•.nions or c lmments:
wQ.l \ K: 11 1
type of Semple(select only one type of sample from types 1 them gh 5 below) —
1.CIRoutine Distribution Sample(MP) 2.❑Repeat lam•.le(AM)Chlorinated:Yes No (from distribulion system after easel.routine)
Chlorine Residual:Total__Free Unsatisfactory ro'dine lab number.
3.Ground Water Rule Source Sample -- —-- - —__._—_
1 S I I Unsatisfactory roitune collect date:
I 1 I
❑Triggered(A/P) Chlorinated:Yes No
El Assessment (AIP)
Chlorine Reridue':Total Free..,
4. Surface or GWt Raw Source Water Sample(Enumeration) + I I
E.COG ❑Fecal fi4rr:E Yee__ l S t I
ID
1 5. Sample Collected fo'Information Only
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
❑E.coliprenni ❑E.cofiabsent
Bacterial Density Results:Total Colifonn_ mom/1pOml. F..col! mon/100m1.
Fecal Colitorm ._� chi /100ml HPC
Replacement Sample Required: ❑TNTC rril
❑Sample too old
ElSamp!eeVolume Damaged Container ❑_ .
Dat ocY7,, tL ,i n — i lab �e Li7
�`1
Receipt Temp C V2
Receipt
method Code S'A9223B or SM9222D
Date Reported tooOH Lab Use Only
DOH L.abSampte
225- �l/l f/�l� (12,..
pO4Fon Ka1•319(eleYpgrjn"
Pie am aNe"evbevpy�re w.lade al...Jan ma sag(nreryw. tpmJl td aflQ37SJ/17 b(nY us nil
Spectra Labs - Kitsap, LLC (Port Orchard)
SPECTRA Laboratories -Kitsap 1786 SE Mile Hill Dr.
Port Orchard,WA 98366
...Where experience matters
Phone: (360)443-7845
JessicaD@spectra-lab.com
www.spectra-lab.com
Spectra Labs - Kitsap, LLC (Port Orchard) received samples for Davis Drilling on Thursday, November 3,
2022 at 1:12 pm. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
135467-01 Bonnie Miller Wellhead 11/02/2022 15:00
135467-02 Wilson Way Wellhead 11/02/2022 10:00
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360) 443-7845 or email us at JessicaD@spectra-lab.com.
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
I1/06/2022 Page 1 of 1
- -- .,
1785 SE Mile Hit
Port Orchard,WA_ ) SPECTRA Lahcratt�rie.. _K ite.1
98386 —Wier!ea mrience ehatreT j--
COLIFORM BACTERIA ANALYSIS FoRIVI
_
Date Sample Collected Time Sample County
Collected
` ' Z� :a� i
Type of Water System(check only one box)
❑Group A 0 Group B KOther__ 'w
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IDS 1
t
System Name: 6 n n I Q (n„ IKK��I ,q r _
T r1 t
t
Contact Person:
Day Phone:( ) Cell Phone:( )
Email:
Send results to:(Print full name.address and Zip code e-mail) -
&A-16-cr-r--.11 'I— 1
- - SAMPLE INFORMATION --~ '--
Sample collected by(name): r /��T�--`
Specific location where sample collected: Special nstnrctions or c mrrents:
lf\JZ\i} f
Type of Sample(select only one typed sample from types 1 throt rgh 5 below)
( 1.0 Routine Distribution Sample(AIR) ( 2.0 Repeat 3am;lle(A'P)
' Chlorinated:Yes No (from distribution sl stem after tinsel.routine) i
Unsatisfactory routine lab number:
! Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample — — - —— i
1 I I S I I I Unsatisfactc.yro•tine collect date: s
I / i
Chlorinated:t'es_ _No ___ I
i 0 Triggered(AP)
❑Assessment (A!P) i Chlorine Residual:Total_—Free_^
4. Surface or GWI Raw Source Water Sample(Enumeration) a
❑E.toll 0 Fecal Filerec Yes_No
5. Sample Cofected for Information Only
LAB USE ONLY DRINKING WATER RESULTS LAB SE OPAy
❑Unsatisfactory Total Coliform Present and !!Satisfactory
❑E,colipresent 0 E.coliabsent
Bacterial Density Results:Total Coliform mon/100ml. E.co mnn 11pp
fit
Fecal Coliform du /100m1. HPC_ f1 ml
•
Replacement Sample Required: ❑TNTC 0 Sample too old
0 Sample Volume 0 Damaged Container 0_T
Da Lab e'
Receipt Temp C' Method Code. SM9223B of SM92220
Date Reported to DOH -'--Lab Use Only
DOH LebSampleir
2z5_ ( 10 ;
OOHm Itiqj
rem Nlrl:If yet mod tit it et Serra.tmisr.or eMOs2S112i1 Ou 7,11,
Me end Wet euteafteet et vettlle a wre.deetewcdAYAYq atr
•t
2199808 MASON CO WA
07/21/2023 09:05 AM NOTCE
1iI I1 II III I Fee
11450
l i 11I I IIII1 IiIII
Return To i ,
/ 114
r t,rA 9�5�� - ••:4 ; _
.LPL
Grantor(s): (1) THERE- q (DOS G �V.ID , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) 1_11 i-- 1- n C e-V - 24 epU C eO-Pin nu;
(
(Abbreviated form:i_e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) o� c2 I I_ LI - 7 Lo - 1 & 1 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_
4
WRIA: I`4
Maximum Annual Average Gallons Por Day: I Jv gallons
Dated on this 2.0 day of- _Lu t , 20 22 .
Signature of Grantor(s):(
(1) 3' t ke , (2)
State of Washington
County of-Meson- \C11304D )
Pagel of
5 1
JUL 1
. t23
I,the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 2.0 day of 3LAL3_ , 20�3_ .
`Th4ix.eS Q. UGYf1.. 10 personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he- (Well signed it.
GIVEN under my hand and official seal the day and year las above written.
-41%;..•�gRtiti� No Public in and for the State of Washington,
�.'My Comm.Expires — residing at Po 1� Or Lr r l ut/A
October 29, : p l 1CI I2O
U7 No.18219Q t� My commission expires: 1 "! j
"•, F WASN0•`•
Page 2 of 2