HomeMy WebLinkAboutWAT2023-00123 - WAT Application - 6/1/2023 0 4 I WATROa. - Ott,
. MASON COUNTY
ENV1R0NMEN .1 MEN ) COMMUNITY DEVELOPMENT
_iNL�H � _/' Permit Assistance Center,Building,Planning
415 N 6`h Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)41R
C. xErioV ED
FAX(360)427-7787
Application for Determination of Water Adequacy JuN - 1 2023
Instructions 61 5 W. Alder Street
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: Kameron & Jenny Gunter Date:
Mailing Address: 5401 SE Lynch Rd Shelton, WA Phone: 360-529-1919
Parcel Number: 31901-50-00015
Type of Water System Reason for Application ,�,,
❑ Public/Community Water System (2 or more 0 Building permit LQ ae�a3- �r/Wi
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
❑ Spring/surface water ❑ 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 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.
1:FIT Forms Drinking Water Revised 1/25/2018
Individual Water Well
/
l7 Water well report(attached to application). Depth 298 ft.7 ()C
❑ Well capacity Test(attached to application) 15 gpm l/O 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.
0 Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 1,'P 15IJ 16U 22=
Water use or limitation recorded N/A Yes El 4FN:ZIQyf95
Well Drilled Date all at) a o
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, 40-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Managem n O hapter
36.70A RCW. O�
Unsatisfactory Determination: ��
Applicant's water supply does not appear adequate to meet the need of its intend u r33 ollowing
reason(s). n'!ASON COUyTY NDV,IiqR .
C'VidENTa-HCALTH
Reviewer's Signatures: 77/Z/207,fEnviron. Health: Date
2 0t,
CSD Director:
Date
t LO R,ox - 00(91, o,
5:33
Gunter, Kameron - Well Log BLH58... N.,EIVEpone
--_ ENVtRGNM NTAL -REC
HEALTH JUN - 1 2023
615 W, Alder Street
W
WATER WELL REPORT DEPARTMENT OF Notice of Intent No E38570
ECO LOGY Unique Ecology.Well ID Tag No.BtJ1580
Type of Work: State of Washington
Construction Site Well Name(if more than one well).
0 Decommission') Dogma!installation NOl No Winer Right Permit/Certificate No.
Proposed Ilse' h Dornretie 0 Industrial D Municipal Properly Owner Name Kameron Gunter
C Dawateriug J irrigation n Ten Well 'i Other Well Street Address 5401 SE Lynch Rd
Construction Type: Method: Mason
FJ New well J Alteration ❑(risen ❑Jetted C('able Tod CountyCity Shelton County
u Deepening a Dike n Drug rra Air* f shtd-Rornry Tax Parcel No. 31901-50-00015
Dimensions:Diameter Of boring 6 n.,w 298 fl_ Was a variance approved for this well? ❑Ya ❑a No
Depth of completed well 298 L
_ __ If yes,what was the variance for?
Constraetim Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
I! I 0 8 in 0 3R._. .025 in. 7.4 I n 7 i 0 Location(see instructions on page 2): 13 WWM or 0 EW M
U 1 LI i _ _ _n. n I n 7 I n Nw '/.-'/.orthe NE %;Section 1 Township 19N Range 3W
El n in. _m U I U U I U in 0 1 n 0 1 n 0 U in Latitude(Example 47.12315)47.169607
_
— Longitude(Example.-I20.12345)-122999979
Perforations: 0 Ya a No Type of perforator used fritter's Log/Construction or Decommission Procedure
No.of ion_ Site of perforations_n by in Formation--Demist by color,character,size of material and sacture.rid the LodantPerforateLedd from 1.to_tl m n below ground surface nature of the material meek Byer macerated,with at least case entry to each change of
Screens: 'Y Yes ❑No it K-Peke b Depth 292 ft. information. Use additional sheets if necessary. ...
Mano(xtun's Name Alloy Machine Works Material From To
Type Stainless Slotted Model No. Brown medium sand,gravel,Bose 0 42
Dimness/6. Slot sicc.018 n.from 293 a-to 298 ft.
Di,,,,nma Skit sire_in.from i to K Brown silty sand.some gravel 42 81
Brown silty sand,tight 81 96
Sand/Firer pack:C Yes a.No Sice of pad,material_in. -
Brown silty sand,wet 96 123
Materiah placed front_IT to_ft.
Brown silty day 123 257
Surface Seal: ss Yes 0 No -ro what depth?20 fl. Brown line silty sand,wet 257 261
!Material mcd n scam B nton to Chips Brown Silty day 261 279
Did any sear,rnman unusable water! n Ycs El No Brown silty day with gravel 279 284
Type of water? Depth astray
Akshod of scaling seats off Multicolored gravel,brown fine to median sand 284
loose,water 298 •
Pomp:M,tmufaaiacr s Name Type:
ti.P._ Pomp intake depth:--A. Designed flow rate:_Spas
Water Lerch:Landsurfaee elevation above mean Sea level 160 1.
Stick-up of top of well casing 1_6 11 abets ground surface
Static water keel 139 g_below top of well casing Date 5/122020
Artesia,pressure an.per square inch Date
Artesian wale is coarolkd by (cap,vales,etc.)
Wen Tests:
Was a psnsptug tat performed?Al No U Yes c. by whom?
Yield_gem with_1.drawsloeo seer__hrs.
Yield_ppm with fl-drawdown after lass. .
Yield_rpm with_ft drawdown after_hn-
Reeossry data Dime-zero w hen pony,is lomat off-water keel measured hart well
top to water krel)
Time Water noel lime Water I meet Time Water l.esel
One of pumping tat
Railer toss 15 gper with 63 fl.drawdown Au 1 Isms _
Air tat_gam with stem seal rt.for_his Date 5/12/2020
Artesian flow_?pin
Temper-mine of water 49 °F Was a chemical analysis made:' C Yes !No Start(late 5/7/2020 Completed Rate 5/12/2020
WELL CONSTRICTION 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 aboive are true to my best knowledge and belief
(Di)Driller 0 Trainee 0 PE-Print Name Josh a Koepp(,[7�j/ Usilling Company Arcadia Drilling Inc.
790
License Signature /✓/ City.St PO Box Shelton,No.2874 City,Stele,Zip WA 98584
IF TRAINEE:Sponsor's License N. Contractor's
Sponsor's Sipnaturc Registration No.ARCADD1098K1 Doc 5/152020
ECY 050-I.20(Rev 09/18) If you need this document In air alternate fanual.please call the Water Resources Program at 360-407-6871.
Persons with hearing loss can call71l for Washing/on Relay Service. Persons with a speech disability can call377.e33-63a1.
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2197793 MASON CO WA
06/0112023 02:13 PM NOTCE
KRMERON GUNTER 1i167363 Ric Fps: $204.50 Pa •s: 2
I IIIIU III III I IIIII IIH flll IIII�I IIIII II I III IIIII IHI IIIII I�
RECEIVED d LSD 3OV-
Return To DO(
KD
it/AI -410v\ Gz�v �'_ _ JUN - 1 2023
SK�'� �yh S l'Si4 615 W. Alder Street
EN`4'1RONNMENTAL
HEALTH
Grantor(s): (1) j Wke krovt A v n.--kc , (2)
Grantee(s): (1) PUBLIC 6_,Ii•Lvtezi4eX)
Legal Description (1) O yVirt' jai FrulA o Gos- , R'?
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 1 C) 1 - 5 Q- 0 n . Q , I 5_
S ITIet 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:
Maximum Annual Average Gallons Per Day: 95C) gallons
Dated on this Q( day of joy1'e, , 20 g. .
Signature of Grantor(s):
(1) C,���U�'' , (2)
State of Washington
County of Mason
Page 1 of 2
s .
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this t s4- day of •ncvh,L , ,
Y--04Ywrcr, M C,dkA.trex 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.
_ANY muss&
)0 ‘sstON EiA G
0+4' iltp ptary ubli and for the State of Washington,
NOTARY ✓ re ' ' gat -litre, WA, CN5/Sti
PUBLIC
My commission expires: 07-17-,7Q 3
s> 4017,r,
'FOFft
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