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HomeMy WebLinkAboutWAT2023-00071 - WAT Application - 4/12/2023 I wfqgotivni i cr \ MASON COUNTY \ : ) COMMUNITY SERVICES APR 12 2023 N. j Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, 615 W. Alder Street Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 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. IPart 1: Applicant/ Parcel Identification Name on Applicant: tit)a even 1405 Date: 3— 3 (— Z3 Mailing Address: 35-1/3 3 Z6•1'`` pi- - $d Phone: Zv7 �7�' y62/ Parcel Number: 3 27 i Z76 v(05-o r-devA/ y . ? d3 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X.Building permit —6I6-1'2.623-On3']0 connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL I Well❑ Spring/surface water 0 Boundary line adjustment 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: 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. J:\EII Forms\Drinking Water Revised 1/25/2018 a Individual Water Well Water well report (attached to application). Depth I30 ft. ia 'Well capacity Test(attached to application) ZO gpm ? SV 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). 6/Z8(a)73 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 141—I 15r 1 161 122n Water use or limitation recorded N/A 0 i 4.F02 f Yes (X06f0 Well Drilled Date S/5//7z 3 Individual Spring/Surface Water I ❑ WDOE permit(attach to application) ❑ Method of disinfection 0 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 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 6.68.040-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. J Unsatisfactory Determination: 441 Pp Applicant's water supply does not appear adequate to meet the needs of its intended usete ing reason(s). ddPi 414 AEG 44� Reviewer's Signatures: 3oNCOUNry ,2023 Environ. Health Date 16 I/�Z3 NFqLTy 2of CSD Director: Date RECEIVED APR 12 2023 - --I Notice of Intent to Construct a 615 W. 4igrNumberet Water Well WE51853 DEPAnTMENT OF This form and required fees MUST BE RECEIVED by the Department ECOLOGY of Ecology 72 HOURS BEFORE you construct a well. Suu 0 wnnmgion 1. Property Owner Name Warren Floss Mailing Address 1 City State Zip Code PO Box 1790 I Shelton WA 98584 2. Consulting Firm(if applicable) Business Name Mailing Address City State Zip Code Email Address Phone Number 3.Well Site Location Tax Parcel Number MasonnName County 322127600050 � Zip Code Street Address City StateWA 98588 860 NE Tahuya River Rd Tahuya Township Range Section %(within 160 acres) %-% (within 40 acres) NE 22N 3W� 12 SW Latitude Degrees Longitude Degrees 4. Project Details No. of Homes Estimated Start Date Project Name 1 4/11/2023 Well use: Domestic Work Type: New Water Right Permit: Not Required 5. Driller Details Professional Name[Architect I I License Number Engineer I Surveyor](if applicable) Phone Number Drilling Company Name (360) 426 3395 ARCADIA DRILLING INC Driller License Number Licensed Driller Name 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/Wells/NoticeOflntentPaymentRequest.aspx Notice Status Date Confirmation I Cash Journal Number Pending 2/6/2023 8:10:37 AM 23020661872815 _ 1_ l,u JUL 2 61023 WATER WELL REPORT W DFPARIMENI OF Notice of Intent No. E51853 ECOLOGY Unique Ecology Well ID Tug No. BPF012 Type of Work: uigIWIII State of Washington g Construction Site Well Name(if more than one well). D Decommission Original installation NOI No. Water Right Permit/Certificate No Proposed Use: l Domestic 0 Industrial 0 Municipal Property Owner Name Warren Hoes 0 Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 860 NE Tahuya River Rd Construction Type: Method: O New well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool City Tahuya County Mason ❑Deepening 0 Other ❑Dug O Air- 0 Mud-Rotary 'fax Parcel No. 322127600050 1 Dimensions: Diameter of boring 6 in.,to 131 ft. Was a variance approved for this well? 0 Yes ❑No Depth of completed well 130 fl. Construction Details: WallIf yes,what was the variance for? Casing Litter Diameter From To Thickness Steel PVC Welded Thread 21 I ❑ 6 in. 0 130 .025 in. 11 1 0 lJ I 0 Location(see instructions on page 2): ©WWM or❑EWM ❑ I ❑ in. to ❑ 1 0 ❑ 1 ❑ NE 'V.-''h of the SW 'h;Section 12 Township 22N Range 3W ❑ I 0 in. _ in. ❑ 1 0 0 1 O ❑ I 0 in in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.414136 Longitude(Example:-120.12345) -123.010349 - - Perforations: 0 Yes al No Type of perforator used _— No.ofperforations Size of perforations_in.by in. Driller's Log/Construction or Decommission Procedure Performed from fl.to_fl.below grate al surface Formation:Describe by color,character,size of material and stnicnue,and the kind and nature of the material in each layer penetrated,with at least one entry for each charge of Screens: 0 Yes 0 No 0 K-Packer r'' Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. ' Diameter Slot size_vt.from R.to it Brown silty sand and gravel,cobbles 0 5 Diameter Slot size in.from ft.to ti Brown silty sand and gravel 5 29 Brown fine sand,some gravel 29 32 Sand/Filter pack:❑Yes O No Size of pack material in Brown silty sand and gravel 32 80 Materials placed from fl.to ft. Brown fine sand,some gravel,silty 80 90 Surface Seal: O Yes 0 No To what depth? 18 ft. Brown siltbound sand and gravel 90 93 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes O No Brown fine sand,silt 93 112 Type of water? Depth of strata Multicolored gravel,brown fine to medium 112 Method of scaling strata off sand,loose,water 130 Multicolored gravel,brown fine sand,tight,wet 130 131 Pump: Manufacturer's Name Type: II.P. _ Pump intake depth:_ft. Designed flow rate. gpm Water Levels: land-surface elevation above mean sea level 266 fl. , Stick-up of top of well casing 1 fl.above ground surface Static water level 70 fl.below top of well casing Date 5/31/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well sse T Was camping test performed? El No ❑Yes r- by whom? Yield gpm with_ft.drawdown after hrs. Yield gpnt with Il.drawdown rifler hrs. Yield gpm with II.drawdown after hrs. Recovery data(tine=zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water I.evel Date of pumping test Railer test_gpm with_fl.drawdown after_hrs. Air test 20 gpm with stein set at 120 ft for 1 hrs. - Date 5/31/23 Artesian flow gpm Temperature of water 49 .F Was a chemical analysis made? 0 Yes O No Start Date 5/31/23 Completed Date 5/31/23 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 are true to my best knowledge and belief 1 Driller❑Trainee❑PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 ��� City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No ARCADDI098K1 Date 5/31/23 ECY 050-1-20(Rev 09/18) ifvolt need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Illimmosimmormairdomisso • • I '� giard Laboratory • 2635 Parkmonf Lane SW, Suite A 01ymp><a`WA 98502 a(�i] vN"'Lg311<p 360 91 7-7010 COLIFORM BACTERIA ANALYSIS FORM JUL 2 6 2Q23 Date Sample Collected Time Sample County 06/28/2023 ed 5 ❑ALI Mason RECEIVED Wall Day Year _� -MI p 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): System Name: Warren Hose 3° tG is • • • ' 9 Contact Person:Arcadia Drillin ,Inc \1121 Day Phone:(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) - Send results full name,address and zip code a e-mail) • arleteGarcadiadrillirg.com AND sueaarcadiadriang.ccm • ' : . . SL P.1 E.INFO I ;: Sample collected by(name):Max - • Specific location where sample collected: Special instructions or comments: tfBPF012 860 NE Tahuya River Rd,Tahuya Type of Sample(selOefilfilitte tyPe elf.-4 kaki m types 1 through 5 below) 1.❑Routine Distribution Sample(AR) 2.❑ Repeat Sample(AM) Chlorinated:Yes No (from cESTrlbution system after unsat.routine) Unsatisfactory routine lab number: Chlorine Residual:Total_Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: ISI I I / Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total_Free ❑Assessment(A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.Cob ❑Fecal FNared Yes No 5.®Sample Collected for Information Only: 04...USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colton Preeelltand. -. •• ®Satisfactory ❑Ecolpresent ❑E.coi absent . Bacterial Density Results:Total Coliform /100m1. E.cofr /100rn1. Fecal Cotforn /100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ braL3 �VZ JO�Z Reference B—IS Receipt Temp C: . Me`wd Code: / zais Date Repotted toOAN_ Lab Use�Us Only. DOH t al.Sarrpl0i 285-49Z ' DOH ram O31J19 Owen Wl1)-Itge uW Sus pWc.5oi b en e5emmHe tan*cal SOD 525.012?MUM cal 711. Tin and oMr/MlaMenr are mated@ at Inv;doh rnpad6tridwaler 0 2200705 MASON CO WA 08/11/2023 11.37 AM NOTCE Return To I 111311111 I I I 11ll 111l l l l 1I II 111l I�I111 I11 N1111 I I 11111111 2 u 3Ccf33 2.61k11tie5,_) FTJ m I c JAyr G cr<ete3 i 0 Grantor(s): (1) ,,,V,f e,„. S S (2) Grantee(s): (1) PUBLIC Legal Description (1) --re__ 6 of �ju' Vt. y l 3`-1 r\u! ► --1 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 3 L 2 I 2 _ -7 (a: - Q 0 D 5 D 5 12 — f 2 2 -- /13 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: i Maximum Annual Average Gallons Per Day: 4d gallons Dated on this / ( day of Ati5 , 20 a .-.- Signature of Grantor(s): (1) , (2) "S`fate of Washington ) County of Mason ) 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 ) , day of Q, ,,j(�L)S. , 20cD 3, Lt. l• --V\ C- uss 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. °' kjASl ,•'gyp :58 •F �t5N Notary Pu lic in and for the State of Washington, :�� NOTARY 5L&0y W+ 1 . residing at 1 �� 21009497 =cD�: PUBLIC My commission expires: Q 3b 2_C52-r-3�F,WASI#s` Page 2 of 2