HomeMy WebLinkAboutWAT2023-00019 - WAT Application - 1/24/2023 RECEIVED
JAN 2 3 2023 WAT L,A - pop i G
615 W. Alder Street
01 a 4 415 N.6th Street
r ' MASON COUNTY Shelton,WA 98584
- . i'i k -�r;1 COMMUNITY SERVICES Shelton:360 42lton, ,Ext.400
� �r>/ Belfair:360-275-4467,Ext.400
} / Bui ng,Planning,Errv'•onmentalHealth,CommunityHeahh E1ma:360-482-5269,EXt.400
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 r .
Name on Applicant: t'L.LVAA •-5}Qrr hQ J tki . i.e VAte: 1 1 -2`-1 - �2-3
Mailing Address: �F,,O O. -I tCu.t..,l -.c 2 hone: `t 25 • 5 i LD' I co `1
Parcel Number: IG 7`t
3)0 I I - ►y - UDOCb
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Ar Building permit 131c120Lh 0O69'49
connections) CI Division of land:
Individual water source(one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
0 Spring/surface water
0 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)
0 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.
0 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
]:\EH Forms\Drinking Water Revised 4/27/2021
Individual Water Well
Water well report(attached to application). Depth •` �• J ft.
X
c Well capacity Test(attached to application) .l gpm 00 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). 177lza ZS
Water Resource Inventory Area (WRIA)/
Development within which WRIA http://eis.co.mason.wa.us/planninq 14 V 15 16 22
Water use or limitation recorded N/A Yes V /lf " Z Ir009 1
Well Drilled Date �1 S � )Z, . A
6
• 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)
ISatisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate s4a4
water indefinitely in the future,or guarantee compliance with all applicable WDOE ater resource regulAti ti't .
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapte ;..:.040-Det ination kJ is e,,
Adequacy for Building Permits are satisfied. Additional Growth Management require •ts may` , Chapter�sr .
36.70A RCW. 043,, ���
❑ Unsatisfactory Determination: F'v' �< ?
Applicant's water supply does not appear adequate to meet the needs of its intended use for th•Cf��
reason(s). it'T,9,
HFgfjir
Reviewer's Signatures:
Environ. Health: ,, Date v) rie6 ?(i Z
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
101
WATER WELL REPORT CURRENT
Notice of Intent No.w652784
Original&Iv copy-Ecology,2"copy-owner,3"copy-driller
f o b COic r Unique EcologyWell ID TagNo. BPC 803
Construction/Decommission(".r"in circle) 9
El Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION Notice Property Owner Name Stephen Butterfield
of Intent Number
Well Street Address 2230 agate rd
PROPOSED USE: ❑✓ Domestic ❑ Industrial 0 Municipal
0 DcWatcr El Irrigation 0 Test Well 0 Other_.....
City Shelton County mason
i
TYPE OF WORK: Owner's number of well(if more than one)_-- Location se 1/4-1/4 11e 1/4 Sec II Twn tat R 3w' hw at 0 cock
a
❑✓ New welle ww'M 0
0 Reconditioned Mulled�❑Dug 0Bored 0 Onvrn
❑Deepened 0 Cable El Rotary ❑Jetted Lat/Long(s,t,r Lat Deg 47.237595 Lat Min/Sec
-----------_.----
DIMENSIONS: Diameter of well 6 inches,drilled)25_ _n. Still REQUIRED) Long Deg 123 Long Min/Sec 015793
Depth of completed well 95.5 fl.
CONSTRUCTION DETAILS TaX Parcel No.32011 1400050
Casing ElWelded 6 " Diam.from+l.5 _ ft.to 95.,5 ft.
Itumlkd: al Liner installed '• Diam.from ft.to �_— _R. CONSTRUCTION OR DECOMMISSION PROCEDURE. 1
Threaded _ " Diam from' _ft.to— ft. •
Perforations: 0 Yes IO No Formation: Descnbe by color,character,size of material and structure,and the kind and
nature of the material in each stratum penetrated,with at least one entry for each change of
Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY.)
SIZE of peels in.by in.and no of pees_.__.from ft.to R. • M,TFRIAI.. I. .IEROM i-_la_-
- Screens: - tits 2I Vo 0 K-Pac Location 95 5-89 5 !Tan,glacial till 0 24
Manufacturer's Name alloy
— — —— grey,silty sands and gravels 24 70
Type ss wire wrap Model No.
— — grey silty sands and gavels,h2o 70 75
Drams _ __Sid we
Sle from 95 5 (I.to 90_5 _____l
Diam s _Slot size from ft.to ft Tan,silted sand and gravels,no h20 _ 75 80
Gravel/Filter packed: ■Yes trni No ❑Size ofgravel/sand I Grey,silty sand and gravel,h20 80 92
Matenals placed from ft. ft
to Grey,silty sand some gravels,small water _ 83 102
Surface Seal:['Yes 0 No To what depth?18_ a. Grey,tight silty sand and gravels 102 107
Material used in seal bentonite clviu Grey,clay 107 115
Did any strata contain unusable water^ 0 Yes I]No
Type of water? Depth of strata
Method of sealing strata off
PUMP: Manufacturer's Name
Type. ,,._,,_._—_H.P —_
WATER LEVELS: land-surface clesataon above mean sea level ft. -----
Static level 45 ft.below top of well Date 6/16/23
Artesian pressure_._...__ lbs.per square inch Date
Artesian water is controlled by
(cap,valve,etc.)
WELL,TESTS: Drawdown is amount water level is lowered below static level
Ws.a(tongs test mwdr"0 vr. ❑No If yr,by wM.m5—_ -.--- -
_—
Yield. gal;nun with R drawdown after his
Yield gal./min.with R.drawdown after hrs •
Yield- gat/min with R.drawdown alter �hrs
Recovery data(time taken as zero when pump turned oln(water levyl measured front well
top to water level)
T,u" Waco•la el — Loy: Wait Lae! Time--_—Water-Level ._ _ .. _ _ _....
Date of test
Bailer lest gat 1min with - ft drawdown after his li Job N
Airiest 5 pl./min.with stem set at 88 -_ft for 1__ , hrs.
Artesian flow .---_-- g.p.m. Date
Temperature of water Was a chemical analysts made' 0 Yes 0 No
Start Date 6/13t23 Completed Date 6/13/23 —
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.
0 Driller 0 Engineer O Trainee Nate { Jacob Hansen Drilling Company Tacoma Pump&Drilling CO.Inc.
Dnller/Engineer/TraineeStgnatuie Address 30316 Mountain Highway
Driller or trainee License No.3181' ,,, ,_. City.State.Zip Graham,WA 98338
'jr TRAINEE. " Contractor's U 113b-3 Driller's Licensed No. Registration No TACOMPD203PF Date
Driller's Signature
---- ---- - - - - Ecology is an Equal Opportunity Employer
ECYoSal-20(Rev 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report.
1d2023 - 000944O
Thurston County Environmental HealthII*.. ... � U � �X,,
2000 Lakeridge Dr.SW *Olympia,WA 98502 --1__.ct-
360 867-2631
THURS ON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County RECEIVED
/Collectedd /�/'/����/�
:./9 �} 7IU�� ICJ ;'3S O PM ' t l�h-2�r)
r.,d,rn Day Year S E P 14 2023
Type of Water System(check only one box) ❑ Private Household
❑Group A ❑Group B rpaOther�inc%+ try,/yam/ 615 W. Alder Street
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:Contact Person:}"wire rA a.,' ?,-- ejq
Day Phone:i(�j�7,576./474 Cell Phone:( )
E-mail:R; A ecKAA,,)K rrry L,f�'1 E_ve.Phone:( )
Send results to:(Print full name,address and zip code or wad address)
it 1A^13„l-J-c.-4;..de)_
Po Box 7A!,._GT''-1e?v_ie. 4._tv4.9B 2,2—__.
_. t.JS�c�-KK.A/✓_2.KI_rryLa_.-Y-4_ Coiv� _____ _.
SAMPLE INFORMATION
Sample collected by(name);
rzI;(rA VOK-I--erek.IS
Specific location or address where sample collected: Special instructions or comments:
2-2-30 G- -4300Le. P.I)
Shel)vn. WA cgg5k _
Type of Sample(must check only one box of#1 through#4 listed below)
11.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
I
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual!Total Free____
❑E.coif-GWR(ANP)
❑Fecal-surface.Owl,springs(nuneraucn) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(AP) Unsatisfactory routine collect date:
❑Other
r /
S
4N Sample Collected for Information Only
Investigative Construction/Repairs Other New W 1 I
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and (['Satisfactory
0 E.cofi present 0 E.coli absent No Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC 0
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code: SM 9223B ❑SM 9222D Date and Time Received: /
SM 92156 0 Enterolert® r%—-2?� auk
Date and Time Analyzed: el— )•-`�-- Date Reported:Q/u%2
Sample Number(DON nember plus five digits) Lab Use Only
0 8 0
DoH Form n ,p0 5 7
3� C�61 ' 't I"1'- Ve,4- , ett 1,kfr
2193091 MASON CO WA
01/24/2023 03:35 PM NOTCE
BUTTERFIELD *183745 Rec Fee• $204 50 Pages 2
11111dt 111111111111111111111111111111111111 IIIIl I III II II I III II I I II II
Return To -�
. x.}ttecfi e ct,
FCi�Z.1-6-4 CiE 52 �
� 1
Grantor(s): (1) h /i(<< �Gt � ;r��P ,9 (2)
Grantee(s): (1) PUBLIC
Legal Description (1) I`�5 C. E (lL, `> `i't t5, l7 `52/It4 57/T,2O
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1), I - ( ` } - G C 6 5 C
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:
Maximum Annual Average Gallons Per Day: i5L') gallons
Dated on this 1-/ day of _ ',i IU A rc/ ,
Signature I Grantor(s):
(1) .z , z,., , �.cf /
L , (2)
State 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 2y' day of Jo-L4O 3 , 20 23 ,
re-1i U c EL+celtt 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 abov ritten.
Notary Public virtott
State of Washington I Notary Public in and or he State o Washington,
ARIANE M PAYSSE
MY COMMISSION EXPIRES residing at M
12/29/2025 My commission expires: 12 2q 2026
•
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