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HomeMy WebLinkAboutWAT2023-00117 - WAT Application - 5/16/2023 ` \VAi Zo23 - 001I i MASON COUNTY i .,Ifil• COMMUNITY SERVICES Pndd.n i Plvvnnl I nvnaimental Health.Community Health klt 415 N 6t"Street, Bldg 8, Shelton WA 98584, 40, Shelton (360)427-9670 ext 400 •'r Belfair (360)275-4467 ext 400 v Elma (360)482-5269 ext 400 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: Remy & Erin Gutierrez Date: 5/16/2023 Mailing Address: 23014 85th Ave W Edmonds, 98(Phone: (425) 530-8220 Parcel Number: 32116-75-00200 Type of Water System Reason for Application 0 Public/Community Water System (2 or more X Building permit 1311C1 20Z3 -005LD8 connections) 0 Division of land: rl Individual water source (one connection), #of Parcels? SPL 53 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) ❑ I am the manager of this water system. The water syst-• as been approved for services. There are presently connection(s) in •. his will be the connection. ❑ I am the manager of this system. This .• ection will be to upgrade or change the use of an existing connection on this system (i.e.: r-• -ational to full time). Please indicate on the following line the nature of this change: This water system • :• e and willing to provide water to this (these)connection(s)without exceeding the limits of to- r ater system or any limits set by state and local regulation. Sig - • e of Water System Manager Date 5/16/2023 This form may be scanned and available for public view at yonyalanUMMILIAip JAB!Fors\Drinking Watcr Revised 1/2S/201$ Individual Water Well Water well report(attached to application).'Depth 120't"mposcd dc_rth ft. /'OP Well capacity Test(attached to application) # ;t.,,, Ilkl,,,„1 l't..np ZS$pP) Gd gd0ypd, 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. yg Satisfactory bacteriological test(attach to application). y(ZO�-New Well to 1w installed by Arcadia Drilling Permit Number - WEC2022-00125 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.masn.wa.us/planning 14 0✓ 15 n16n 22n Water use or limitation recorded N/A ✓ Yesi_,li>,��-21,171jZ Well Drilled Date �(/ /Gv Z r z5 Individual Spring/Surface Water r ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe that this water source can pro '• -t least 800 gallons per day; and/or provides water at a rate of 2 gallons per min • .ased on the following observations. Author of S • ent Date -elationship 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 su••ly •f water indefinitely in the future,or guarantee compliance with all applicable WDOE wate t A ••ri • -• E D Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.•'� ' or. n71'• of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. AUG 3 0 2023 ❑ Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended r;UutMcE1 PIRONMENTAL HEALTH reason(s)_ DJA Reviewer's Signatures: / /7 3 Environ. Health: — Date 2 of2 CSD Director: Date AUG 2 5 2023 RECEIVED WATER WELL REPORT DEPARUMEN1 of Notice of Intent No. WE49963 ECOLOGY Unique Ecology Well ID Tag No. BPF072 Type of Work: %14State of Washington :I Construction Site Well Name(if more than one well). 0 Decommission m==:> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Remy Gutierrez ❑Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 120 E Spirit Cl E Construction Type: Method: El New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug ©Air- 0 Mud-Rame)' fax Parcel No. 32116-75-00200 Dimensions: Diameter of boring 6 in,to 113 ft Was a variance approved for this well'? 0 Yes ❑' No Depth of completed well 110 ft If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread O l ❑ 6 in 0 110 .025 in. ai I ❑ O I 0 Location(sec instructions on page 2): E WWM or 0 EWM ❑ I 0 _in. la ❑ I ❑ ❑ 1 ❑ NE '/.-Yr of the SW 'VI;Section 16 Township 21N Range 3W ❑ I ❑ _in. _ in ❑ I ❑ ❑ I ❑ ❑ 1 ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.306592 N Longitude(Example:-120.12345) -123.073241 W Perforations: 0 Yes ©No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations_in.by_in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from R.to_R.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes EI No 0 K-Packer '__--:' Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. 2 Diameter_ Slot size in.from _R.to_R. Brown fine sandy gravel,silty,loose,dry 0 Diameter_ Slot size_in.from R.to_ft. Brown gravelly fine sand,tight,dry 2 14 Brown fine to medium sandy gravel,sharp, 14 Sand/Filter pack:0 Yes G.1 No Size of pack material_in. silt bound,dry 63 Materials placed from ft.to ft. Brown gravelly medium sand,tight,wet 63 79 Surface Seal: ®Yes 0 No To what depth? 19 ft. Brown fine to medium sandy gravel,tight,weeps 79 91 Material used in seal Bentonite Chips Multi colored medium to coarse sand,tight,water 91 103 Did any strata contain unusable water? 0 Yes O No Type of water? Depth of strata Multi colored coarse sandy gravel,loose.water 103 111 Method of scaling strata off Brown medium sandy gravel,tight,wet 111 113 Pump: Manufacturer's Name Type: H.P. Pump intake depth: ft. Designed flow rate: gptn Water Levels: Land-surface elevation above mean sea level 341 ft. Stick-up of top of well casing 1_1 ft.above ground surface Static water level 62 fl.below top of well casing Date 8/2/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Wan a pumping test performed? El No 0 Yes --) by whom? Yield _gpnm with ft.drawdown after_hrs. Yield _gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after_hrs. Recovery data(lime=zero when pump is tuned off-water level measured fionu well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test_spin with_ft drawdown allot_hrs. Air test 25 gpm with stein set at 100 ft.for 1 hrs. I Date 8/2/23 Artesian now gpm J Temperature of water 52 ^F Was a chemical analysis made? 0 Yes gl No Start Date 8/2/23 Completed Date 8/2/23 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. L7 Driller 0 Trainee 0 PE-Pr' e Rogeray Phythian Drilling Company Arcadia Drilling Inc. Signature 7/ Z` Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Lic nse No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 8/2/23 ECY 050-1-20(Rev 09/18) if your need this document in an alternate formal,please call the Hater Resources Program as 360--107-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833.6341. Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 d�rr.3a�d 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 08/04/2023 1 1 ®F.,a MASON c. M, Day Yes ---- ❑P• Aka') Type of Water System(check only one box) AUG 2 5 2023 ❑Group A ❑Group 8 ®Other_ Group A and Group B Systems-Provide from Water Facilities Inventory(WFI). RECEIVED System Name: REMY GUTIERREZ Contact Person:Arcadia Drilling, Inc Day Phone:(360 )426-3395 Cell Phone( ) Email: Eve.Phone:( Send results to:(Print full name,address and zip code or e•mad) arfeta@arcadiadnli ng com AND suetarcarbadnuing corn SAMPLE INFORMATION Sample collected by(name):SHAD Specific location where sample collected: Special instructions or comments. #BPF072 120 E Spirit Ct E,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A/P) 2.0 Repeat Sample(A1P) Chlorinated:Yes_ _ _ No (from distribution system atter unsal rounne) Unsatisfactory routine lab number Chlorine Residual:Total Free • 3 Ground Water Rule Source Sample — -— Unsatisfactory routine collect date: BSI i Chlorinated:Yes_ No ❑Triggered(A/P) Chlorine Residual.Total ` Free ❑Assessment (AP) —� — 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.cob ❑Fecal Altered Yes No 5.©Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and )?I Satisfactory 0 E.co/i present 0 E cot absent Bacterial Density Results:Total Colifonn___ _/100m1. E.col I100m1. Fecal Colifonn_ ___/100m1. HPC _/1 mi. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container 0 Recei ltTem C' J01 Method Code spa. Date Reported to DOH Lab Use Only DOH Lab-Sampletr 285- roe ram 1031-319(eeecwe 9fi111(.N sou Now nrpthaea n an Manreve tons,aA 199.52S 012/(TOCYTTY d 711). The eM caw atvmas de e.UeY s row dot n porbwenp ew 5theI -3-oo5(a 2198182 MASON CO WA I. 06/12/2023 11:45 AM NOTCE REMY GUTIERREZ #187664 Rio Fie: $204.50 Pages 2 I Jill IIIII 11111!111 III1 MII Ill H1 rI IDIlll W III Iill Return To RECL1Vr_.D f 3 b i z-j ' A vc JUN 1 2 2023 C—Av QA 5, `IJc 9 Via- (0 615 W. Alder Street Grantor(s):(1) Re.my GLO-i esre Z. , (2) Grantee(s): (1) PUBLIC Tr- -O c: S(....tve y S/30, S S 1 /3 S Legal Description (1) Ufkrjeg lr1)E~i1� 1,�r1C\ (Abbreviated` form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1)._ 2 1 I LP _ '7 5 _ 0 0 a O d (,„ -Q‘ 9.3 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`'I Maximum Annual Average Gallons Per Day: J�� gaitons Dated on this o T day of fi ia.y , 20 _. Sfgnatu f Grant (s): (1) / h , (2) State of Washington ) County of Meson S f,014,-•�csy'r ) I Page 1 of 2 I,the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this -Ill-day of f^r1" , 20 . 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 and year last above written. Notary Public in and for the State of Washington, Notary Public residing at 6-d,,,9,-)S State of Washington RYAN PRUDNICK My commission expires: CL / 11 �. License # 207427 Commission Expires April 18, 2027 Page 2 of 2