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HomeMy WebLinkAboutWAT2023-00181 - WAT Application - 6/27/202371111111:- , , MASON COUNTY COMMUNITY DEVELOPMENT 26 9'92 - 00 Il _. Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, 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. Part 1: Applicant/ Parcel Identification Name on Applicant: MACKENZIE STEVENS Date: 06-27-23 Mailing Address: P.O. BOX 2137 Phone: 360-490-4205 Parcel Number: 22032-24-90010 Type of Water System Reason for Application 0 Public/Community Water System (2 or more 0 Building permit 17k12023- Y*351-4 connections) 0 Division of land: El Individual water source (one connection), #of Parcels? SPL O Well 0 Boundary line adjustment O Spring/surface water ❑ Other(explain) 0 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. O 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 06-27-23 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Watcr Revised 1/25/2018 AMOK \ Individual Water Well Water well report (attached to application). Depth ! Z ft. Well capacity Test (attached to application) 70 gpm ?g00 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). ,04/7O23 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14 >(I 151 1mi 1221 I Water use or limitation recorded N/A 0 Yes `]/MN:21 006g Well Drilled Date 7/I7/za3 Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ 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 uate supply of water indefinitely in the future,or guarantee compliance with all applicable WDOE a 4 e•ulations. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.04 -D ` ' t Adequacy for Building Permits are satisfied. Additional Growth Management requirements may ap• rt, 36.70A RCW. SEP 1 Unsatisfactory Determination: MASONSn 32023 Applicant's water supply does not appear adequate to meet the needs of its intendedW4' f following reason(s). DJAON�'dENTAL HEA (TH Reviewer's Signatures: Environ. Health: . Date Y/8/ 0/23 2 of 2 CSD Director: Date WATER WELL REPORT „t. :,?_:_:J DEPARTMENT OF Notice of Intent No. WE52949 ECOLOGY Unique Ecology Well ID Tag No. BPF026 Type of Work State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission r :, Original installation NO1 No. Water Right Permit/Certificate No. Proposed Use: l Domestic ❑Industrial 0 Municipal Property Owner Name Mackenzie Stevens 0 Dewateri❑g 0 Irrigation 0 Test Well 0 Other Well Street Address 7590 SE Lynch Rd. Construction Type: Method: O New well 0 Alteration 0 Driven ❑Jetted ❑Cable Tool City Shelton County Mason 0 Deepening ❑Other 0 Dug RI Air- ❑Mud-Rotary Tax Parcel No. 220322490010 Dimensions: Diameter of boring 6 in.,to 92 _ft. Was a variance approved for this well? ❑Yes O No Depth of completed well 92 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread RIO 8 in. a 88 .025 in. I I I ❑ O I 0 Location(sec instructions on page 2): ©WWM or 0 EWM ❑ 1 ❑ in. — — in. ❑ I 0 ❑ 1 ❑ NW n%-%of the NE %;Section 32 Township 20N Range 2W ❑ 1 0 _in. _ _ in. ❑ I 0 0 I 0 ❑ I ❑ in. _ — —in. ❑ I 0 0 1 ❑ Latitude(Example:47.12345) 47.181318 Longitude(Example:-120.12345) -122.862016 Perforations: 0 Yes lia 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: El Yes ❑No lil K-Packer u Depth 86 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless Slotted Model No. Diameter 5" Slot size.010 in.from 87 ft.to 92 ft. Brown silty sand and gravel 0 8 Diameter_ Slot size in.from ft.to ft. Gray silty sand and gravel 8 21 Gray silt 21 45 Sand/Filter pack:0 Yes M No Size of pack material in Gray silty clay,some gravel 45 52 Materials placed from ft.to ft. Multicolored gravel,brown fine to medium 52 Surface Seal: M Yes 0 No To what depth? 19 ft. sand,water 87 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes El No Gray fine to medium sand,some black 87 Type of water? Depth of strata gravel,water 92 Method of sealing strata off Gray silty clay 92 Pump: Manufacturer's Name Type: H.P._ Pump intake depth: R. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 205 ft. Stick-up of lop of well casing 1_5 fl.above ground surface Static water level 23 ft.below top of well casing Date 7/17/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? O No 0 Yes c' by whom? Yield _gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hers. Yield gpm with ft.drawdown after his. Recovery data(time—zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer lest gpm with ft drawdown after hrs. Air test 20 gpm with stem set at 60 ft.for 1 hrs. — Date 7/17/23 Artesian flow gpm _ Temperature of water 50 e F Was a chemical analysis made? ❑Yes 17 No Start Date 7/14/23 Completed Date 7/17/23 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 0 PE-Print N Jos Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 .."%--_ /c","City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Licen No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 7/17/23 ECY 050-1-20(Rev 09/I8) 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. \11:66teris.12. Vanguard Laboratory "V 2635 Parkmont Lane SW,Suite A • Olympia WA 98502 vg„IR etD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM 4!, t� Date Sample Collected Time Sample County V Collected n� O) �J[\ 08/01/2023 3 5 n oH,, Mason AbnVi Day Year31 PIA 44-b\b‘ vvJ Type of Water System(check only one box) ❑Group A El B El Other ,(§` Group A and Group B Systems-Provide from Water Facilites Inventory(WFI): System Name: Makenzie Stevens Contact Person:Arcadia Drilling,Inc Day Phone(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results la:(Print full name,address and zip code or e-mail) arleta©arcadiadnllvp.com AND aueOeroadiadrilling.corn SAMPLE INFORMATION Sample collected by(name):SETH Specific location where sample collected: Special instructions or comments: #DPF026 7590 SE Lynch Rd,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(A/P) Chlorinated.Yes No (from distribution system after cnsat rout be) Unsatisfactory routine lab number: Chlorine Residual:Total Free 3.Ground Water Rule Source Sample — —— S Unsatisfactory routine collect date: / I Chlorinated:Yes _ No ❑Triggered(A/P) Chlorine Residual Total__ Free ❑Assessment (ARP) 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.soli ❑Fecal Frtered Y.s_No 5.©Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory ❑Ecoli present ❑E.coli absent Bacterial Density Results:Total Coliform_— /100mi. E.coli /100ml. Fecal Coliform _/100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/Time Received: Lab Reference Number 750 V? QTQ2-!2- Receipt Temp C: Method Code: $ SM223$ Dale Reported to DOH lab Use Only. DOH Lab-Samplep 285- DOH rom,a3J1.719(aea..ONt•).e yo,,naao tns pWYO4M n an emroen Mmal till ede 525.0127:TD(YTTV mi 711) TM ua other pa01oasm.a amide at aviw don.i poMvrinpwehr IGl 2vZ.�j OOS�i • • 2200069 MASON CO WA Return To 07/27/2023 09:01 AM NOTCE STEVENS p169186 Roc Fee: $204.50 Pages: 2 h1 Y�cK txnz t 1= 51"�-1101-) 1111111111111 II IIII I'1ItIIIII1111111111I1111111111:iI I III l.1IIII I!11111 -?() 6ox a•1,3 K)ho a tole WA cie5 -I [Ea JUL 272023 • RECEIVED Grantor(s): (1) 1fi 14G►1����Q1- Lr)�, (2) Grantee(s): (1) PUBLIC Legal Description (1) 64" I Dr 5p .D D (Abbreviated form:i.e. lot, block,tplat or section, township, range) Assessor's Tax Parcel: (1) .2. a Q 3 s A - I 0 0 1 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 Maximum Annual Average Gallons Per Day: I�D gallons Dated on this V5 day of ciU , 20 3. Signature of Grantor( : (1) State of Washing n ) County of Mason ot111';c0MNII ? .�4 V4 Np74gy • •� Page 1 of 2 • tic s • • . r I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this o25th day of <. I0ly , 20 a , NttcktnLt, S4evths 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 year last above written. yil AA art f'k rp Notary Public in and for the State of Washington, residing at She III nl 14.114 My commission expires: '7 /5 '02-490V, Page 2 of 2