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HomeMy WebLinkAboutWAT2023-00069 - WAT Application - 3/14/2023r .., - IL era WA"I' 3- r7op(�Z� ..: MASON COUNTY COMMUNITY SERVICES ENVIRONMENTAL ( HE Building, Environmental Health,Community Health ALTH !Ly kY:" 415 N 6'h Street, Bldg 8, Shelton WA 98584, ` ra^ Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (3 *`38 5 A4GQ- FAX(360)427-7787 Application for Determination of Water AdequatO 1 0 2523 Instructions 615 W Alder Street 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: 'V\i6 LIZ:4\r l/� am ' Date: a, . I 2. 0 2'� 7SZZ 0Pa e_ t4 )Y Mailing Address: -rkctor.A r wA QgyhG, Phone: 253lit- 6� Parcel Number: 323332200050 Type of Water System Reason for Application Public/Community Water System (2 or more ( Building permit Q)1.—O aOR,3— C0370 connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment O Spring/surface water ❑ Other(explain) ❑ 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.TI I Forms,Drinking Water Revised 1/25/2018 Individual Water Well gee 14/07(T-000F0 Water well report(attached to application). Depth V/ ft. Well capacity Test(attached to application) gpm vv(/ 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. XSatisfactory bacteriological test (attach to application). 6/2 f/'0z3 Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14 15r.16[—]22U�,-,�trr� Water use or limitation recorded N/A Yels1 >�1 :Z2V caw Well Drilled Date 7/[/ �lf Individual Spring/Surface Water ❑ WDOE permit(attach to application) O 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: f/.. 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: itIP ' Applicant's water supply does not appear adequate to meet the needs of its intended use for the followin . reason(s). V 1/0 Mq Se Reviewer's Signatures: SONCUoNTY ?6 cu23 Environ. Health: Date ?/z6/C0.Z ��NMF,yrgl y CSD Director: Date FgC 2 of TN 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 • l Construction Site Well Name(if more than one well): ❑ Decommission ey Original installation NOI No. Water Right Permit/Certificatc No. Proposed Use: ©Domestic 0 Industrial ❑Municipal Property Owner Name NW Loaaina _ 0 Dcwatering 0 Irrigation 0 Test Well 0 Other Well Street Address 26141 NE N Shore Rd Construction Type: Method: OO New well ❑Alteration ❑Driven ❑Jetted ❑O Cable Tool City Tahuva County Mason 0 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? Cl Yes ❑No Depth of completed well 65 ft. If ycs,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ❑. I ❑ 6 in. +1 45 1/4 in. D I ❑ EIO Location(see instructions on page 2): D WWM or 0 EWM N I ❑ ti in. 68 70 1/4 in. M 1 ❑ O I ❑ NW y-1,4 of the NW V.;Section 33 Township 23N Range 3W ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. _ _ in. ❑ I ❑ ❑ I ❑ , 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. Driiler's Log/Construction or Decommission Procedure Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,-nd the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: LI Yes ❑No ❑O K-Packer r:=:> Depth 42 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson • Material From To Type stainless Model No. 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 n. Light brown sand&gravel saturated 38 65 Clay bound sand&gravel 35 80 Sand/Filter pack:❑Yes ❑No Size of pack material in. -- Materials placed from ft.to ft. Surface Seal: ❑' Yes ❑No To what depth? 18 ft. Cut drive shoe at 68'pull casing back to 45' 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 Type: H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of lop 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 ❑Ycs t=4> by whom? L— 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 front well top to water level) Time Water Level Time 'Water Level Timc Water Level Date of pumping test _ Bailer test 1 gpm with 38_5 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? ❑Yes 0 No Start Date 6/7/23 Completed Date 7/1/2;•_ 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. 0 Driller❑Trainee 0 PE—Print Name Emily Davis Drilling Company Davis Drilling Signature CA r?" 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.DAVISD11100A _ Date July 2023 1786 SE We till 4 SPECTRA Labora<ories - Kitsap Port Orchard, _ -----•------— _.__.—_...•_.._____._, 98366 ...Where experience matters ='r ` '`..;(4111r.RM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected - (O /Zi ` q : c : os\c cr moo, Day Year ----— —_- Type of Water System(check only one box) , ❑Group A 0 Group B htOther t(I Group A and Group B Systems-Provide from Water Facilities Inventr y(WFI): ID# System Name: 2( /1 t N. r(Q 2 E . S Contact Person: Day Phone:( ) J Cell Phone:( ) Email: Serd results to:(Print full name,address and zlp code e-mail) � )� ^ SAMPLE INFORMATION Sample co98cted by(name): wM --VY Specific location where sa collected: Special instn;bor.s or comments: iV\it \ _I! Type of Sample(select only one type of sample from types 1 through 5 below) _ 1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(A/P) II Chlorinated:Yes No {from dislnb:roon systun after unsat.routine) Unsatisfadory 1autine lab number: Chlorine Residual:Total Five_ 3.Ground Water Rule Source Sample —'-`-— —'-— S 1 I Unsatisfactory routine collect date: I I Chlorinated:Yes_ No Triggered(�) Chlorine Residual: Mal Free___. Atcnvsment(A/P) —, 4. Surface or GWI Raw Source Water Sample(Enumeration) I S t 1 ) v E.wli ❑FM-1 Fit red Yen .,Ic_..__ 5.ptSample Collected for information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colitorm Present and tisfacto►y 0 E.coii present ❑E.coli absent 8actectal Density Results:Total Coliform men/100rnl. E•col/ mon/100mL Fecal Coliform du I10Oml. HPC _/1 ml { Replacement Sample Required: 0 TNTC D Sa rtpfe too old 0 Sample Volume 0 Damaged Container Lab Reference Nuuher l Dat0e2a y a i 4 0 2:a.3?�- _. l Receipt Tema C°' Methods• SMP223BorSM9222D _1 Date Repotted to D(M Lab Use Only: DOH Leb•Samplee nc*ram 7171J10 Lead..Q417)•/to.,noel No pUkaOan in an d em+°n kernel d BOUf1SAt_7(iDyr1V cal 711} 17ie.‘1s,.ptfakc+[oft awixaa a t.v..AIragP.#7• , Return To 2202380 MASON CO WA 09/20/2023 09.31 AM NOTCE b,/ ,/ _,r /,JsTAFs GUSTRFSON 0190973 Rac Fee $204 50 Pauus�es 2 11$111111111111111111111114111111131111111 RECEIVED Grantor(s): (1) k/awtr✓i Gos+rt. //tvL (2) Grantee(s): (1) PUBLIC ' 6r .i Legal Description (1) - 1 0a r3L.4 *I$-o14 A knoll'''. � Carr�� .5 yy/c0 `is,/ (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 3 ? 3 3 3 - 0 0 0 3 0 e-c33 1-Aki23 (zN43 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: 15 Maximum Annual Average Gallons Per Day: 9 ✓ 0 gallons Dated on this "O day of SCP i- , 20 3 Signature of Grantor(s): - (1) , (2) State of Washington ) County of Mason ) 7 [E 11 WI Tyr' Page 1 of 2 i 1, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 2_0. ,day of Q1p rti,ker-- , , rsn eri vck a-Cs o tv 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. 17;64 / N4/tie ublic in and for the State of Washington, \.�` .1 • • N��,�% residing at ��� -cv\ t�' M?0;• 4, 1-0• = My commission expires: O 7/. 2 /2 0 2 y � �pTARy �• •. FXp, 1lZ,.•6(s. • F /, WAS, AS,\`" Page 2 of 2