HomeMy WebLinkAboutWAT2023-00084 - WAT Application - 4/26/2023 WAT ao a a- m8 y
MASON COUNTY
COMMUNITY DEVELOPMENT
MEN "-i Permit Assistance Center,Building,Planning
EN��R�N 415 N 6th Street, Bldg 8, Shelton WA 98584, A
REicifugi 427-9670 ext 400 :• Belfair: (360)275-4467 ext 400 ❖ Elma: (360)4 9.e4-4 0
FAX(360)427-7787 2073
Application for Determination of Water Adequacy OR 2
615 W. Alder Street
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: f i, l p, M DAS- Date. �/� ‘7)11
G
Mailing Address: Phone: �65=�or- 3/oZ 0
Parcel Number: f,3,2 - yl Y O/d)-
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit gG„ 17420,23 Y56)
connections) El Division of land:
IA Individual water source (one connection), #of Parcels'? SPL
.ZI Well El Boundary line adjustment
❑ Spring/surface water
❑ 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:
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.
0 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:\lilt Forms\Drinking Water Revised I/25/2018
t f
Individual Water Well
[ Water well report (attached to application). Depth ✓3i ft.
Well capacity Test (attached to application) �L- gpm 8'00 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.
tif Satisfactory bacteriological test (attach to application). g'// '/zoz3
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14/115E7 16n 221-1
Water use or limitation recorded N/A 0 Yes i 1 pz19ST/
Well Drilled Date V23700 z3
Individual Spring/Surface Water
❑ WDOE permit (attach to application)
0 Method of disinfection
0 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 adec •�ply of
water indefinitely in the future, or guarantee compliance with all applicable WDOE water resourc- -• .L'ons.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determi +.AI
Adequacy for Building Permits are satisfied. Additional Growth Management regients mv ply. �r'
36.70A RCW. NCO Cie ,
__ Unsatisfactory Determination: ��J c'g ,
Applicant's water supply does not appear adequate to meet the needs of its intended use for t3owing
Reviewer's Signatures: �����
Environ. Health: Date /73/ 01_1
2 ore
CSD Director: Date
l ..
AUG
141023
WATER WELL REPORT _ :7.-::_..'. DEPARTMENT OF' Notice of Intent No. WE51494 RE
- ECOLOGY Unique Ecology Well ID Tag No.BNM841 D
Type of Work: `",,�, State of wvashi'gton
CJ Construction Site Well Name(if more than one well):
0 Decommission b Original installation NOI No. Water Right Remit/Certificate No.
Proposed Use; M Domestic C Induutial f7 Municipal Property Owner Name PHILIP SIMONS
0 Dewatering O Irrigation L:•fest Well Cl Other
Well Street Address 1290 TIMBER TIDES DR
Construction Type: Method:
*I New well C Aheration C Driven Ci Jetted .Cable Tool City UNION County MASON
0 Deepening ❑Other C Dug I I Air- J Mud-Rotary Tax Parcel No.322354390162 —....__
Dimensions: Diameter of boring 6 in..to 535 ft. •
Was a variance approved for this well? ❑Yes No
Depth of completed well 535 ft.
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From to Thickness Steel PVC Welded Thread
M I ❑ 6 in. +1 525 .250 in. ❑O I 0 ❑' I C Location(sex:instructions on page 2): C!7 WWM or❑EWM
0i0 in. _ in. 0 1 0 0 1 0 SE '/s-%of the SE 'h;Section 35 Township 22N Range 3 _
❑ 10 in. _ _ in. n 1 O O 10
0 I ❑ in. in. ❑ 1 ❑ d 1 C Latitude(Example:47.12345)47.348125
Longitude(Example:-120.12345) -123.021138
Perforations: 0 Yes L9 No Type of perforator used
No.of perforations Size of pert-tit-aliens in.by in. Driller's Log/Construction or Decommission Procedure
Perforated from ft.to ft.below ground surface Formation:Describe by color,character.stet 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 O No I K.-Packer b Depth_ft. information. Use additional sheets if necessary. _
Manufacturer's Name ._- Material From To
Type STANLESS Model No.
Diameter 6 in. Slot size 10 in.from 525 ft.to 535 ft. CLAY&GRAVEL BROWN 0 520
Diameter_ in. Slot size in,from ft.to ft. SAND H2O BROWN 520 535_
Sand/Filter pack:0 Yes e I No Sire of pack material in. I --
Materials placed from ti.to ft.
Surface Seal: z'Yes C No To what depth? 20 ft.
Material used in seal BENTONITE
Did any strata contain unusable water? D Yes L!No
Type of water? Depth of strata_ —
Method of sealing strata off
Pump: Manufacturer's Name GOULDS Type: SUB
H.P.3 Pump intake depth:57S P.. Designed flow rate: 10 gpm
Water Levels: Land-surface elevation above mean sea level ft
Stick-up of top of well casing 1 ft.above ground surface t
q Static water level 495 ft.below top of well easing Date 8-18-23 I
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve.etc.)
Well Tests:
Was a pumping test performed? Cl No ti Yes c7 by whom?
Yield 1 gpm with40 ft.drawdown after 4 hrs.
Yield gpm with ft.drawdowm after ____hrs.
Yield gpm with_ft.drawdown after hrs. _
Recovery data(time zero when pump is tamed off--water level measured from well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test
Bailer test gpm with ft.drawdown after_hrs.
Air test gpm with stem set at ft.for hrs. Date
Artesian flow gpm
Temperature of water "F Was a chemical analysis made? C Yes M No Start Date 4-27-23 Completed Date 6-25-23
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
construction stand s.Materials used and the information reported above arc trite to my hest knowledge and belief.
J Driller C lfiPE-Print Name CLAYTON PITTS Drilling Company COOLWATER DRILLING,INC.
) Signature 4, If Address 10921 NW HOLLY RD __ _.__
License: r. 16 City,State,Zip BREMERTON WA 98312 __-.__.__
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.COOLWD1941QM Date 8-23-23
ECY 050-1-20(Rev 11/18) 1(you need this document in an alternate format.please call the Water Resources Program at
360-407_6872. Per.van.s with roaming lave can call 711 far I4'ashingtua Relay Sen•ir e. Persons with a.petwlr di.vuhibty can call
R77-833-6341.
126276 Twelve I r 1
Trees Ln NW l i
f
S:e.0 SPECTRA Laboratoric. Kitsap i
I Poulsbo,WA i ..... .___. .
1 98370 ...Whet*ctycricnrc mallets M
(360)779.5141 1 COLIFORM BACTERIA ANALYSIS FORM
I Date Sample Collected I lime Sample County
1 V 1 a(i z 4)Z Waded
❑ ��1 c.S Cyr-.
*ell -----Day Yaw �' V „PN
1 Type of Water System(dtede only one bar)
ifFGroup A 0 Group 13 AOther _-- -- _____
Group A and Group 8 Systems-Provide from Water Facilities Inventory(WFI):
ID# 4, 0
System Name: 40
6 2` Contact Person: C Cv 11,✓G 6.e,- �-o /l'�;..1-'" 20 �
I DayPhone:3(ap- C -9GC7.5 RCP Cell Phone: R <
-t
I Email: ; Eve.Phone: — - FQ
Sendfasutts b:(Prig Waaa r scletress aid rip code a mull aim*to;.Mdionk copy of nouns)
..(iC)/ts1A r. lr,/fir'^-''
6.001 Jcikie..c1y,�t,••. • ffvt`VIA,/. Cc2.e21,
SAMPLE INFORMATION
Semple collected by(name): i.; �r, < •
��
1/=pit / .
fSpecific bcabon wham sample collected: Special instructions or comments:
i
L\2 c.Tr,m\De v--1'+c e S D. --
Type of Sample(check only one box)
1.0 Routine Distribution Sample(AlP) 2.0 Repeat Sample(AIP)
Chlorinated:Yes 0 No k (from distitOon system alter uraat ruutne)
Unsatisfactory routine lab number:
Chlorine Residua!:Total_—Free_
3.Ground Water Rule Source Sample _ ----_- ——
S
I 1 Unsatisfactory routine collect date:
Chlorinated Yes No
❑Triggered (AP)
Chlorine Residual Total_Free_._-_
1 ❑Assessment(A/P) -
4.Surface or GWI Raw Source Water Sample(Enumeration) S I I
D E.coif ❑Fecal Flexed res_!:o __.
5. a Calecied for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory ,
0 E.cot present 0 E.coliabsent
Bacterial Density Results:Total Coliform __-mprs'100m1.E.co6 mpnit00ml.
Fecal Cclifonn_.-_ cfuf100m1.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
l`Dalai-.ps Received_
Lab Reference NumOer
Receipt Temp C: Metllod M9223 OT-COUNT!SM9222D
'_- AU619 n:e Aetk rand INN lair wed'Moors)a argyes
Date Reputed We Csaeers a Am u.•npeip a*low csa,a.,at d
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2195801 MASON CO WA
04/11/2023 11 55 AM NOTCE
SIMONS 4185031 Rec Fea: $204.50 Pages 2
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Return To R' P i
TED
Philip and Debra Simons L. �j
1133 N Grape Dr., Apt C 203 ENVIRONMENTAL NAY - L 2023
Moses Lake, WA 98837 HEALTH 615 W. Alder Street
Grantor(s): (1) Philip Simons , (2) Debra Simons •
Grantee(s): (1) PUBLIC
Legal Description (1) LOT 2 OF SP #619 PTN TR 16 S 1/210-213
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 2 3 5 - 4 3 - 9 0 1 6 2
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 g�/1 day of 4p/"// , 2073.
Signature of Grantor(s): �,`�
(1) e , (2) ‘ ).�f "{ LA
State of Washington
0 County of Mason
Page 1 of 2
r
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this day of n , 20 a3,
W]ra L.G*1 S (pllI II p C..fr9M 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 t above written.
`-, /-->_- ------
ary •til in and for the State of Washington,
RENEEJOHNSON I ::..ing at ktySeg 1- l-e-
Notary Public '
Statem ofss Washington
1032 My commission expires: 3v.V. t9 ac a6
Commission ar 110327 � �
My Comm. Expires Jun 19, 2025
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2195801 Page 2 of 2 04/11/2023 11:55:15 AM Mason County, WA