HomeMy WebLinkAboutWAT2023-00165 - WAT Application - 7/2/2023 WAT 2.a23 - OD I LP 3
415 N.611t Street
MASON COUNTY Shelton,WA 98584
COMMUNITY DEVELOPMENT Shelton:360- -9670,Ext.400
licltair.360-275275-4467.Ext.400
Permit AssIstarce Center,Building,Planning Elrna: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: test-b c MA 2L-'f Date: -7 �3
Mailing Address: 620 Jt_ v�nc8 Phone h 4ef 6 5-o1- 703-(56 S
Parcel Number: 32°3 a_ 13-cx_o 10 0
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more p' Building permit i�' 14 ZD�22- 00-74
connections) ❑ Division of land:
tFp Individual water source (one connection), #of Parcels? SPL
7 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
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.
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 eater Revised 414/201K
yrr
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Individual Water Well
Water well report(attached to application). Depth 13 .7 ft.
Well capacity Test (attached to application) 20 gpm 7gOO 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). 7/Iy/70.73
/_(
1 Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14X 15 16 22
Water use or limitation recorded N/A Yes A A 'itrztlfte3
Well Drilled Date /i3/7073
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 6.6 4 -Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirer t r
36.70A RCW. R
ovr..
E .
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for tiULfoll3 irr�23
reason(s). bfASON G
COUNTY ENVIROA MENTAL HE lTH
Reviewer's Signatures: -7/V'/DJA
Environ. Health: Date /(5//L 3
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
Notice of Intent to Construct a Notice Number
Water Well WE52961
DEVARiMEHi Of ECOLOGY This form and required fees MUST BE RECEIVED by the Department
State o.w„hnttOn of Ecology 72 HOURS BEFORE you construct a well.
1. Property Owner
Name
I Wade Marler
Mailing Address City State Zip Code
PO Box 1790 Shelton WA 98584
2. Consulting Firm(if applicable)
Business Name
Mailing Address City State Zip Code
Email Address Phone Number
3. Well Site Location
County Name Tax Parcel Number
Mason 320321300100
Street Address City State Zip Code
771 SE Cole Rd Shelton WA 98584
Township Range Section %(within 160 acres) '/.-% (within 40 acres) SW
20N 3W 32 NE
Latitude Degrees Longitude Degrees
i
4. Project Details
Estimated Start Date 7/13/2023 Project Name I No.of Homes 1
Well use: Domestic Work Type: New Water Right Permit: Not Required
5. Driller Details
Professional Name[Architect I License Number
Engineer I Surveyor)(if applicable)
Drilling Company Name Phone Number
_ ARCADIA DRILLING INC _ (360) 426-3395
Licensed Driller Name Driller License Number
ROGERAY PHYTHIAN 2053
Comments
6. Fee Summary _
Total amount due for wells with casing diameter less than 12": $200.00
Remit payment to: Department of Ecology Cashiering Unit, P.O. Box 47611, Olympia WA 98504-7611
OR Pay online at https://appswr.ecology.wa.gov/wellconstruction/WeIIs/NoticeOflntentPaymentRequest.aspx
INotice Status Date Confirmation I Cash Journal Number
Pending 5/31/2023 7:57:49 AM
1
,r•r •
WATER WELL REPORT " ' `'" DLPANIMENI DI Notice of Intent No. WE52961
ECOLOGY unique Ecology Well ID Tag No. BPF025
Type of Rork: - State of Washington
Construction Site Well Name(if more than one well)
❑ Decommission Original installation NOI No. Water Right Permit/Certificate No.
Proposer)Use: L�Domestic 0 Industrial 0 Municipal Property Owner Name Wade Mauler
0 Dewatcring 0 Imgation 0 Test Well 0 Other
Well Street Address 70 SE Carpenter Rd.
Construction Type: Method:
O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
Cl Deepening ❑Other f7 Dug 1A Air- fl Mttd-Rotary Tax Parcel No. 32032-13-00100
Dimensions: Diameter of boring 6 in..to 137 ft a
fl Was a variance approved for this well'.) 0 Yes l No
Depth of completed well 135
Construction Derails: yap If yes,what was the variance for?
Casing liner Diameter From To Thickness Steel PVC Welded Thread
0 ❑ s in. 0 13S .025 in. 3 I 0 Cl0 Location(see instructions on page 2): 3 WWM or❑EWM
❑ i D in. _ _ _in. ❑ 1 ❑ ❑ • ❑ SW '/.-'/.of the NE 'Y..;Section 32 Township 20N Range 3W
❑ in. _ in. 0 I ❑ Cl 0
DID in _ — in. ❑ 1 ❑ ❑ ❑ Latitude(Example 47.12345) 47.179629 _
Longitude(Example.-120.12345) -123.082703
Perforations: 0 Yes Gel No Type of perforator used
No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
Perforated from ft.to R.below ground surface Formation Describe by color,character,size of material and structure.and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: ❑Yes El No 0 K.-Packer > Depth fl. information. Use additional sheets if necessary.
Manufacnur's Name Material From To
Type Model No.
Diameter Slot size in.from ft.to_it. Brown sandy loam 0 4
Diameter Slot size in from ft to—ft Brown medium sand and gravel 4 15
Brown sand and gravel with clay binder 15 21
Sand/Filter pack:0 Yes O No Size of pack material in
Brown medium sand and gravel 21 88
Materials placed from ft.to fl Brown silty clay 88 89
Surface Seal: El Yes 0 No To what depth" 19 ft. Gray silt,some gravel 89 108
.''laterial used in seal Bentonite Chips
Did any strata contain tmusable water? 0 Yes El No Brown silly clay 108 112
Type of water! Depth of strata Gray clay 112 120
Method of sealing strata off Black gravel,medium black sand,water 120 135
Black silty sand and gravel,wet 135 137
Pump: Manufacturer's Name Type
H.P. Pump intake depth: ft. Designed flow rate. ppm
Water Levels: Land-surface elevation above mean sea level 204 ft.
Stick-up of top of well casing 1 ft.above ground surface
Static water level 77 li.below top of well casing Date 7/13/23
Artesian pressure lbs.per square inch Date_
Artesian water is controlled by (cap,valve,ctc.) _—
%'ell Tests:
Was a pumping test performed? FJ No Li Yes -- by whom?
Yield gpm with fl.drawdown after hrs.
Yield gpm with_ ft.drawdown after ....,hrs.
Yield —gpm with_It.drawdown after hrs.
Recovery data(time-zero when pump is turned off water level measured from well
rap to water level)
'lime Water Level Time Water Level Time Water Level
Date of pumping test___________
Bailer test gpm with fl.drawdown after_hrs.
Air test 20 gpm with stem set at 120 ft.for 1 hrs. - Date 7/13/23
Artesian flow gpm
Temperature of water 49 F Was a chemical analysis made? ❑Yes El No Start Date 7/13/23 Completed Date 7/13/23
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.
17 Driller 0 Trainee D. PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc.
Signature Address PO Box 1790
I.icensc No. 2874 7c City,State,Zip Shelton,WA 98584
IF"(RANEE Sponsor's Lim a No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 7/13/23
ECY 050-1-20(Rev 09/18) If you treed this document in an alternate format,please call the Water Resources Program to 360.407-6e872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-5'33-6341.
Vanguard Laboratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
vg2g:Mtr, 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected A MASON
07/19/2023 AM
2 PM
ricnth Day Yaar ----
Type of Water System(check only one box)
❑Group A ❑Group B ®Other -
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IOC
System Name WADE MARLER
Contact Person:Arcadia Drilling.Inc
Day Phone:(360 )426-3395 Cell Phone:(
Email. Eve.Phone:( )
Send results to:(Print full name address a:d zip code Dr email)
arteta@arcadadnnrig.corn AND vrre@nrcadradrr.hrg corn
SAMPLE INFORMATION
Sample collected by(name) MAX
Specific location where sample collected Special instructions or comments:
#BPF025 70 SE Carpenter Rd:Shelton
Type of Sample(select only one type of sample from types 1 through 5 below)
1 ❑Routine Distribution Sample(AIR) 2 ❑ Repeat Sample(AP)
(from cDstriburol system after cnsat rcr:bne)
Chlorinated-Yes_,_-_---No___.
Unsatisfactory routine lab number
Chlorine Residual:Total_._....-.Free___
3 Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S I l
Chlorinated:Yes .--No__...
❑Triggered(a'P) Chlorine Residual.Total . Free
❑Assessment (A!P)
4 Surface or GWI Raw Source Water Sample(Enumeration)
S
❑E.coil ❑Fecal Flared Yes Na r
5.gE Sample Collected fit Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and gb Satisfactory
❑E.coli present ❑E.Cool absent
Bacterial Density Results Total Conform—_ _,___-l100m1. E.coli 1100m1.
FecalColiform _ /100m1. HPC /1 nil.
Replacement Sample Required: ❑TNTC ❑Sample too oaf
❑ Sample Volume 0 Damaged Container ❑
CaterTime Received ac Reference Winder
716.1 3._ —/600 VZ.3 7(9-iy
Recap Temp 0•: Method Code
�B
s•g M
—
nate Reported to� DOH y� Lab Use Only
LA-C,rf4
DOH Lab-SaPple4
285-716 -{
.. ;^'m•�:, .-+•ecavetto 1 era rreamnaCsakr-n•ets:aa•e M tat cea OS15791:rp!Yr.•aM NI;
er4./tv 73.K6KM d•f.a't's a vau oa Nf aawanrempe1N
mier
2199483 MASON CO WA
07/13/2023 01:19 PM NOTCE
MRRLER #188713 Rec Fee: $204.50 Pages: 2
IIIIII1 III911111111111111111!!11111111111111111111I1 I11111111III III
Return To
6208 Nc 637 tti Ave_
Ua -*--j \ J ►49& 2-
Grantor(s): (1) ''l acLe V . M4r/.-€A , (2)
Grantee(s): (1) PUBLIC -�~ _
Legal Description (1) _e J b C `�- 5� nE flL s E
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 0 3 2 - 1 3 - 0 a I O C)
,33zi 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: 1'4
Maximum Annual Average Gallons Per Day: C150 gallons
Dated on this 1, day of 3 `� l�G , 20 2 3
Signature ofGrantor(s):
(1) VV/AL 1U�—fi✓ , (2)
State of Washington
County of-Masao-CIQv K
Page 1 of 2
F
• I ` . ,
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•
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this day of -Su \ .)\ , 20 ,
D PIDAjo.v 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 year last above written.000ttiiistrtio,, ' '
.� � No ry Public in and for the State of Washington,
�tJTA9f'� �'
1 ' residing at y01V1�(A�r?,V aC�1�V1Gl�f-6y,
My Comm,Expires4
August27,2025 . = My commission expires: gust 2-1 2O25
i No.21031494 Z
""F WAS\A',.\`‘
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