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HomeMy WebLinkAboutWAT2023-00068 - WAT Application - 4/10/2023 e WA'F Q 3- Ooo(oF rate`` <:• ct� MASON COUNTY EN�A i 1 -:� t COMMUNITY SERVICES NM G , / O SJ v 1R yro H1 t�a``av Building,Planning Environmental Health,Community Health • tAE-AL1� 415 N 6t"Street, Bldg 8, Shelton WA 98584, `L—�L,!t'.r Shelton: (360)427-9670 ext 400 •. Belfair: (360)275-4467 ext 400 Elma: (360)482-569 ext 400 r`L1 FAX(360)427-7787 "jut? K ' 0 20,11 Application for Determination of Water AdegL/vv ceder St reEt 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: IJtrtl/I afe 5T 1.064 1,J(,i I.Ohi ate: 0 3. t 11. 2a 23 Mailing Address: 2�'22 fAeometi ,Ja 198vn F Phone: 253.'121• g364 Parcel Number: 3 2 3 3?2 3 errd ZO Type of Water System Reason for Application Public/Community Water System (2 or more ,Qf Building permit QbLAnDR-5-- (5o76-7tf connections) El Division of land: j , Individual water source (one connection), #of Parcels? SPL j _ Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) El 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:AEH Forms\Drinking Water Revised I,25I201 S Individual Water Well )16 6-S 'gee WC z013-oobgp Water well report (attached to application). Depth 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). 6/z( 0o7-3 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14n 1512,[1611 222� Water use or limitation recorded N/A Ye /3FAr=220Z371 Well Drilled Date Wi/Z013 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 adequ to o'`, water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regula�n�/ Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040 urination of Adequacy for Building Permits are satisfied. Additional Growth Management restiOments nia4pEpillf 9hap1ter 36.70A RCW. `Oti COUNry�NV (V J ❑ Unsatisfactory Determination: RQN Applicant's water supply does not appear adequate to meet the needs of its intended use for thel.�glltwin NTA(HEAT reason(s). N Reviewer's Signatures: �/ /7 Environ. Health: Date `7 ( (UZ3 2°' CSD Director: Date WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE52891 ECOLOGY Unique Ecology Well ID Tag No. BPQ 165 Type of Work: State.of Washington -- • O Construction Site Well Name(if more than one well): ❑ Decommission Original installation NC)!No. Water Right Permit/Certificate No. Proposed Use: l Domestic ❑Industrial ❑Municipal Property Owner Name NW Lodging _ ❑Dewatcring ❑Irrigation 0 Test Well ❑Other Well Street Address 26141 NE N Shore Rd Construction Type: Method: New well ❑Alteration ❑Driven ❑Jetted O Cable Tool City Tahuva County Mason ❑Deepening ❑Other _. ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 32?32290140 Dimensions: Diameter of boring 6 in.,to 80 ft. Was a variance approved for this well? ❑ Yes ❑N' Depth of completed well 65 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter Front To Thickness Steel PVC Welded Thread I ❑ 6 in. +1 45 1/4 itt. O I ❑ O I ❑ Location(see instructions on page 2): n WWM or❑ EWM © I ❑ 6 in. 68 70 1/4 in. O I ❑ O I ❑ NW /,-y.ofthe NW '/.;Section 33 Township 23N Range 3W ❑ I ❑ in. in. ❑ I ❑ DIE ❑ I 0 in. in. ❑ I ❑ ❑ 1 ❑ , Latitude(Example:47.12345) 47.44451 Longitude(Example:-120.12345) -123.07920 Perforations: ❑Yes ❑O No Type of perforator used — No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated from fl.to ft.below ground surface Formation:Describe by color,character,size of material and structure,rnd the kind and nature of the material in each layer penetrated.with at least one entry for each change of Screens: E Yes ❑No ❑O K-Packer ' > Depth 42 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Type stainless Model No. Material From To Diameter 5 in. Slot size 14 in.from 45 ft.to 65 ft. Reddish brown conglomerate 0 38 Diameter in. Slot size in.from ft.to ft. Light brown sand&gravel saturated _ 38 — 65 Clay bound sand&gravel 65 80 Sand/Filter pack:❑Yes ❑No Size of pack material in. — — Materials placed from ft.to ft. Surface Seal: 0 Yes ❑No To what depth? 18 ft. — Material used in seal bentonite Cut drive shoe at 68'pull casing back to 45' Did any strata contain unusable water? ❑Yes ❑No — Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: — —— H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing ft.above ground surface Static water level 26.5 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 ' 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 Water Level Timc Water Level r' Date of pumping test Bailer test 1 gpm with38.5 ft.drawdown afterl hrs. Air test gpm with stem set at ft.for hrs. — Date Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes ❑No Start Date 6/7/23 Completed Date 7/112: WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance wi,h 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 Name Emily Davis Drilling Company Davis Drilling Signature 000— Address 340 NE Davis Farm Rd License No.3142 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI1100A _ Date July 2023 ` t 1786 SE Mite Hill Port tam ui ECTRA Labora_ories - Kitsap 98366 a .E;. ..Where experience matters 4111 RM BACTERIA ANALYSIS FORM Date Sample uoechd r Time Sample County consoled z1 5. os tkp: )scn Mont Clay You Type of Water System(check only one box) ❑Group A 0 Group B Other Po Group A and Group B Systems-Provide from Water Facikttes Invenk*y(WFI): IDff System Name: L(.,f[J J MEN. SI' (e r2-6( Contact Person: Day Phone:( ) Cell Phone:( ) Email: Sent results to(Print full name,adds and zip code email) ---akW12:Zir t SAMPLE INFORMATION Sample collected by(name): clrn i — Specific� i` t location where sa collected: Special instn:flora or comments: V \ Type of Semple(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(A/P) Chlorinated'Yes No ((turn dstnb;roan sysRm alter unsaL routine) Unsabstactory routine tab number Chbrine Residual:Total Free 3.Ground Water Rule Source Sample ——— '--——— — S Unsatisfactory Wine collect date: I_ I Chlorinated:Yes_ —No El Triggered(AP) Chlorine Residual: eta Free_.___. ❑Assessment(A/P) -q 4. Surface or GWI Raw Source Water Sample(Enunerat✓✓n) ISI I u E.co/i ❑Fecaat r Yr., Nc 5.piSample Collected for Infornmeioe Only. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colton Present and sfactory 0 E.aoli present ❑E.ccfi absent Bacterial Density Results:Total Coliform mum 1100nt1. E.ao(I_ mpn I100rnt Fecal Coliform cfti 1100rni. HPC _/1 ml {i Replacement Sampla Required: (]TNTC D Sa role too aid Sample Volume 0 Damaged Container 0 p Lab Reference Relabel' rjatrO • Receipt Temp C^ o�0d CodeSM°223B or SM9222D Date Repated tO DOH J UN 7 2 '13 tab Use Only: —i DOH Leb,Sernple# 0(O50 (9 I -� DOH Fate p113fe Newer ar/r).rpu wadi'ra*.afar at an losntlw trash d (mo M all'n., TIt$and ably tltiatoas are malaise a ra rdah.tsi¢v#fNacmi . 2202379MASON CO WA Return To oT� . _ 1 GUSTAFSON It190973 Ric Fee: 5204.50 Pages 2 ?7R'W-�W (4JS-1-4 fc JQ-ri 111111111111111IIDDII i1lii1i111111111111111111111ii11l1 2;12 IJ P. 4- 7,-x_ Si-- 4'i ,Gil -rg cr r4 l u-/-4 9/3*0 SEP 2 g 2023 RECEIVED Grantor(s): (1)uWlovl 6JS 1 JE i -/1/W -. , (2) Grantee(s): (1) PUBLIC GOUT Lod 1 Legal Description (1)t a. ctt I51/4#1F 0 4 AF�h a090193 tr/�b�' 5 ' 41/44; 5 kS/y (Abbreviated form:i.e. lot, block, plat or section,rr township, range) Assessor's Tax Parcel: (1) 3v 3 3 5 - a 3 - 0 0 I O St_c 3 rC in! 2 ; +z-A 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: i S Maximum Annual Average Gallons Per Day: f SO gallons Dated on this Q,v day of p/. , 20 Signature of Grant (s): �- (1) , (2) State of Washington ) County of Mason ) 1) U''AOUIF SEP 202023 ;� Page 1 of 2 By __ • I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this Zi2tNday of Sin(e ,6e r2o 23, ay.non Cn f1�-(-2,Vc o✓\ 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. 1� t l t l t)J "ii Vie( 4/{": \;�J��tET y��,��� 1. ary Public in and for the State of Washington, • �� �,sE a2o,<,•tiy', residing at l�aiti u �pTAgy �'• _ My commission expires: (57(23 (2 t2-4( Page 2 of 2