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Home My WebLink AboutWAT2023-00155 - WAT Application - 6/30/2023 • 4 N MASON COUNTY • COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning II D 1.1 415 N 6'h Street, Bldg 8, Shelton WA 98584, ..� E N V I R O N M ENolAT2)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 •: Elma: (360)482-5269 ext 40 JUN 3 0 2023 FAX(360)427-7787 l` HEALTH RECEIVED Application for Determination of Water Adequacy hlcier 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: Curtis Janhunen Date: 05.10.2023 Mailing Address: 1704 Bel-Aire Ave, Aberdeen V�Phone: 360-533-4908 Parcel Number: 52004-50-00037 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more El Building permit a LQada,5-007 7 connections) ❑ Division of land: p Individual water source (one connection), #of Parcels? SPL O Well El Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) El 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) O 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 05.10.2023 This form may be scanned and available for public view at www.co.mason.wa.us. J\011 Forms',Drinking Water Revised I/25/201 g Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) gpm 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). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 1151 1161—(221—I Water use or limitation recorded N/A 0 Yes ( 1 Well Drilled . . . . . Date 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 6.68.040-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date -of CSD Director: Date ��Pad - 0O7�7 p,GG �013 2200678 MASON CO WA • ,v° 08/10/2023 03.51 PM NOTCE eCe JANHUNEN *189662 Rec Fee $204.50 Pages: 2 �ohn JanLneh RECEIVED S 3 Cliffe- s Francisco, A- AUG 10 2023 615 W. Alder Street Grantor(s): (1) jOk 64 1-0kO'\ , (2) Kral-me. aArvAe\ ,r Grantee(s): (1) PUBLIC Legal Description (1) NAHWATZEL BEACH TR 37 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 5 2 0 0 4 _ 5 0 _ 0 0 0 3 7 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: 22 Maximum Annual Average Gallons Per Day: 3,000 gallons Dated on this t° • day of AV 01 VL S , 20 Zv. Signature of Grantor(s): (1) , (2) State f ashin n ) Count 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 lO day of Pi.VctV 5* , 20 23, ,_\oY ,n and y--r S+l,,\4_, personally appeared before me, who is known to be signer of the above instrument, and acknowle••-d that he - (they) signed it. GIVEN under my hand and official seal the da ..ad ye. - •ve itten •ta P.b• in an• for the State of Washington, �t�tttt�tiiiu�� residing at k& SOV\ C,oV�-'W 0 STANT //i�i _2- 7 Mycommission expires:S—' AP'F‘\0-202,4'o • :c° a0A� N. I• _ ▪ oa PUB�\G o�0 li �aNumbst'f�(' Page 2 of 2 01,'baO2 0073-7 RECEIVED ENVIRONMENTAL o:0 HEALTH JUL 1 0 2023 JUL 1 2 20 WATER WELL REPORT DEPARTMENT OF e �� nten WE52862 EEOLGG y Wf��Uniqueoogel ag No. BPQ 191 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission => Original installation NO1 No. Water Right Permit/Certificate No. Proposed Use: O Domestic C Industrial ❑Municipal Property Owner Name Curt Janhunen C Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 421 West Nahwatzel Beach Road Construction Type: Method: O New well ❑Alteration ❑Driven 0 Jetted M Cable Tool City Shelton County Mason [I Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 520045000037 Dimensions: Diameter of boring 6 in.,to 47 ft. Was a variance approved for this well? ❑Yes ❑No Depth of completed well 47 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread 17 I ❑ 6 in. +1 42 in. O I 0 l ! 0 location(see instructions on page 2): C WWM or O EWM ❑ 1 ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ SE '/.-1/2 of the NE '/.;Section 4 Township 20N Range 5W ❑ I ❑ in. _ in. ❑ 1 ❑ ❑ 1 ❑ O 1 O in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.246770 Longitude(Example:-120.12345) -123.327154 Perforations: ❑Yes 0 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 ft.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: 0 Yes ❑No O K-Packer => Depth 39 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Model No. Diameter 5 in. Slot size 10 in.from 42 fl.to 47 ft. Brown sand&gravel 0 15 Diameter in. Slot size in.from ft.to n. Greenish clay 15 18 Reddish brown conglomerate 18 28 Sand/Filter pack:0 Yes ❑No Size of pack material in. Materials placed from fl.to ft. Reddish brown sand&gravel wet 28 43 Light brown large gravel wb 43 47 Surface Seal: M Yes ❑No To what depth? 18 ft. Material used in seal bentonite Did any strata contain unusable water? ❑Yes ❑No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name poulds Type:sub 11.P. 3/4 Pump intake depth:40 ft. Designed flow rate: 15 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing fl.above ground surface Static water level 19 ft.below top of well casing Date Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ❑No ❑Yes b by whom? Yield . gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with_ft drawdown after hrs. Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Watcr Level Time Water Level Date of pumping test Bailer test 18 gpm with 5 ft.drawdown aflerl_hrs. Air test gpm with steer set at ft.for hrs. — Date Artesian flow_gpm Temperature of water _"F Was a chemical analysis made? ❑Yes ❑No Start Date 6/23/23 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 standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller❑Trainee -1 PE—Print Name Emily Davis Drilling Company.Davis Drilling Signature Address 340 NE Davis Farm Rd License No.3 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISD11100A Date June 2023 ECY 050-1-20(Rev 08/19)if you 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. WATER WELL/DEWATERING SYSTEM CONSTRUCTION PROCESS After a well is constructed,modified or decommissioned,a well report must be filed within 30 days to the Department of Ecology.Well reports are filled out by the person who constructed the well.This is typically a Washington State licensed well operator. The following form is used for water wells and dewatering systems only.Below are the instructions for filling out a water well report.After the form has been printed and filled out,it should be mailed to the Department of Ecology Regional Office responsible for the area the well work was conducted. INSTRUCTIONS Type of Work—This form is used for BOTH construction and decommissioning of a well.Please check the appropriate box.For decommissioning—enter the original construction Notice of Intent No.here(if available). Dimensions—Nominal diameter of uncased boring(drill bit size)and total depth drilled.Depth of completed well may be different from total depth drilled. Construction Details—Choose either Casing or Liner.Enter nominal diameter and depth range.Check the type of material and whether it was welded or threaded.A description of mechanically locked liners may be added to the Driller's Log/Construction Procedures section. Perforations—Well casing perforations;read each statement and answer appropriately. Screens—Well screens and screen assembly information.A K-packer is designed to provide a sand tight seal between a well screen assembly and casing. Sand/Filter Pack—Read each statement and answer appropriately. Surface Seal—Read each statement and answer accurately. Water Levels—Casing stick-up means the height,in feet,the well casing rises above ground surface(preferably measured to the hundredth[ie.2.34 ft]).Static water level is the depth,in feet,to the water surface inside the well or boring (preferably measured to the hundredth[ie.6.78 ft]).A static water level implies the measurement is not disturbed by pumping or drilling,or a nearby well that is pumping.Include the date the measurement was taken.Artesian pressure is the gauge reading of a flowing artesian well with the valve closed(shut-in pressure),reported in psi. Well Tests—A pumping test is the process of pumping groundwater out of a well and measuring the water level response through time.This process is the best way to determine the efficiency of the well.Drawdown is the amount the water level is lowered below static level when pumping.A bailer test is a common way to test well efficiency while cable-tool drilling,whereby a tool called a bailer is used to pull up and dump water onto the ground,simulating pumping.An air test is commonly used when drilling an air-rotary well to estimate well production,since an air compressor is always on hand. Notice of Intent No.—The number issued by the Department of Ecology for tracking purposes(e.g.,W I23456).Should start with a W,A or D for this form. Unique Ecology Well ID Tag No.—The number issued by the Department of Ecology that is stamped on a metal tag that is attached to the actual well.(e.g.,AAA-000) Site Well Name(if more than one well): If there is more than one well on the site,you may identify each well with a site well name or number and place it in this space.This is different from the Unique Ecology Well ID Tag No. Water Right Permit/Certificate No.—If the well will use more than 5,000 gallons per day or irrigate more than V2 acre of land,you must have a water right.This number should be written here. Property Owner Name—The name of the property owner. Well Street Address—The physical address where the well is located.(Note:NOT the mailing address.) City—City where the well is located. County—County where the well is located. Tax Parcel No.—County tax parcel number-enter ROW for right-of-way. Was a variance approved?—A variance request is submitted to a regional well coordinator if the regulations cannot be met. Explain the request here. Location—The quarter-quarter,quarter,section,township and range(TRS)of the well.For example:the SE'/-'/ of the NE''A,S10,T2ON,R05—and then check box for West or East of the Willamette Meridian[WWM/EWM]for range.The web-based State Well Report Viewer in map view is one of the best places to determine well location using the TRS system. Latitude/Longitude—Using a GPS or web-based coordinates,enter the latitude and longitude of the well using the WGS84 coordinate system.Please input to the fifth decimal place. Driller's Log/Construction or Decommission Procedure—Describe the geologic materials encountered while boring. Also,decommissioning procedures,additional location notes,or unusual aspects of the project can be written here. Well Construction Certification—Read the statements;enter the Driller and Drilling Company information;sign and date in the blanks provided.A sponsor is the licensed driller that is responsible for a trainee according to 173-162 WAC. ECY 050-1-20(Rev 08/19) lfyou 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. S LQ 3 -0X73 7 Spectra Labs - Kitsap, LLC (Poulsbo) L. SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste. C ...Where experience masters Poulsbo,WA 98370 RECEIVED Phone: (360)779-5141 JUL 10 2023 www speti N MENTAL HEALTH 615 W. Alder Street Spectra Labs- Kitsap, LLC (Poulsbo)received samples for Davis Drilling on Tuesday,June 27, 2023 at 12:10 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 228765-01 421 Nahwatzel Beach Rd Well Head 06/26/2023 10:05 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.spectra-lab.com. JUL 1 2 2023 RECEIVED This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 06/30/2023 Page 1 of 1 e 26276 Twelve TrcesLnNW I' Ste.0 11 SPECTRA Labvratarics - Kits ay Poulsbo,WA __ __ _Wisn ssperlsace waters 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County CP f ILV t ' Collected S O Matft Day Year :_ 0 PM Type of Water System(check only one boa) ❑Group A 0 Group B ( Other I-Pl 1 Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IDtt System Name: yZ ice, hvuct-e I at Contact Person: Day Phone: Cell Phone: Email: Eve.Phone: Send resells to:(Prim tut nano,address and tip code a email above for elecuontc Copy Onside) � it' _ t/7�11 ��e \) a �r SAMPLE INFORMATIO Sample collected by(name): Specific location where sample laded: S al instructions or comments: • Type of Sample(check only one box) 1.❑Routine Distribution Sample(AR) 2.0 Repeat Sample(AIPI Chlorinated:Yes 0 No 0 (from distribution system alter unsat routine) Unsatisfactory routine lab number. Chlorine Residual:Total_Free_ 3.Ground Water Rule Source Sample — — — Unsatisfactoryroutine colect date: S I l Chlorinated:Yes No ❑Triggered (A/P) Chlorine Residual:Total Free_ ❑Assessment(AIP) 4.Surface or GWI Raw Source Water Sample(Enumeration) I S I I ❑O E.coil ❑Fecal Feared Yee—Ne 5.5fir ample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS .LAB USE ONLY ❑Unsatisfactory Total Coliform Present and )23tatlsfactory ❑E.coN present 0 LooNabsent Bacterial Density Results:Total Coilorm mpn/100m1.E.coN mpn/100m1. Fecal Coliform ____cful100m1. HPC cfu/1m1. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑ _ _ IrD Dalerti R ¢d Lab Reference Number Receipt Temp C': Method Co •S14922313 7 T-COUNTI SM9222D ninpat meMu.dt dodo.mr r.by ° t1IV 1I10�3 9 1�'"2 81013 .die oldpo..dde, . �.�a. .r"'• .fplee er..dn.aw� d Y Jdb719 i41 rd n en..7.Ne rot11 deleor di.n0enpoee111. DOH Lab—Semple Ct ma.eels nee.ry n ee area red end er..ierld e. named by Iv Me.eb7-so r.pa Sp n t Vet rd po 010-�_ D( ae .N1ebwae.or�es.eexprodl�Spann lm Lox. MN earn r331.31e(.ettana/1n