HomeMy WebLinkAboutWAT2023-00231 - WAT Application - 10/2/2023 WAT 9,0?-3 - COP-3 I
415 N.6'h Street
MASON COUNTY Shelton,WA 98584
F17 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair.360-275-4467,Ext.400
Buidmg Planning,Environmental Health Community Health Elma: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
Name on Applicant: T.:a/Aci SCO �((. Gat2Q eZ Date:
Mailing Address: 1-5\3 W. Co lc.. ST. It S Phone: ( 6o I46323'6 I
Parcel Number: '319 o 7 - t I - OO Q� O
Type of Water System . Reason for Application
0 Public/Community Water System (2 or more ,,.Ef Building permit 3La2.0•23- 0/047
,.connections) ❑ Division of land:
yr Individual water source(one connection), #of Parcels? SPL
l�Well 0 Boundary line adjustment
0 Spring/surface water 0 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)
El 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:\EH Forms\Drinking Water Kr
AIMMIII
Individual Water Well
/Water well report(attached to application). Depth 11 l 137 ft. /-�v
Well capacity Test(attached to application) U gpm > SO 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)
1
Development within which WRIA http://gis.co.mason.wa.us/planninq 14 .15 16 22
Water use or limitation recorded N/A Yes X *'1 0O(-I?._
4 Well Drilled Date V3I2-3
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:
o 2,
Environ. Health: Date `�'
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT 0EPAR(MINI of Notice of Intent No WE52002
ECOLOGY Unique Ecology Well 1D Tag No BPF030
Type of Work Mpg State of Washington
• Construction Site Well Name(if more than one well)
O Decommission Original installation NOI No. Water Right Permit/Certificate No - -
Proposed Use: RI Domestic 0 Industrial 0 Municipal Property Owner Name Fransisco Gonzalez
❑Dewatering ❑Irrigation 0 Test Well 0 Other
Well Street Address 4717 US Hwy 101
Construction Type: Method:
L9 New well IA Alteration LI Omen 0 Jetted ❑Cable Tool City Shelton County Mason
❑Deepening ❑Other ❑Dug ®Air- ❑Nlud-Rows- Tax Parcel No 319074100030
Dimension: Diameter of boning 6 m,to 137
Iepth of completed well 137 lt Was a variance approved for this well' Yes No]
Construction Details: Wall If yes,what was the variance for? - -
Casing Liner Diameter Front lit thickness Steel PVC Welded thread
RID 6 in. 0 133 .025 in. 3 1 ❑ i ❑ Location(see instructions on page 2): O WWM or❑EWM
❑ 1 O in. _ is D ( O D I ❑ SE V.-%of the SE Y.;Section 7 Township 19N Range 3W
❑ 10 in. _ is ❑ 1 0 D 1 D
❑ i O in. in D I D D I ❑ Latitude(Example•47.12345)47.147167
Longitude(Example:-120.12345) -123.097161
Perforation: O Yes 9 No Type of perforator reed
No of perforation Size ofprarfeafioes_in.by_in. Driller's Log/Construction or Decommission Procedure
Perforated from ft.to_ft.below wood fttiloe Formation Dessx.he byand color,character,size of material and structure,and the kind
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: RI Yes 0 No K-Packer Depth 131 ft information Use additional sheets if necessary
Manufacturer's Name AIOY Machine WOfkS Material From To
Type Stainless Slotted Model No.
Diameter 5- Slot size.010 in.from 132 ft.to 137 R. Brown silty sand and gravel,loose 0 9
Diameter Slot size_in.from ft.to ft. Brown silty sand and Gravel,tight 9 15
Sand/Filter pack❑Yes 1 No Size of pack material ,n Brown medium sand and gravel 15 48
Materials placed from O.to ft Brown sandy silt 48 50
Multicolored pea gravel,brown fine sand 50 63
Surface Seal: iiil Yes 0 No To what depth^ 19 R. Brown fine sand 63 86
Material used in seal Bentonite Chips
Did any strata contain unusable water" 0 Yes El No Gray silty clay 86 98
Type of water? Depth of strata_ Brown fine to medium sand,some gravel,water 98 137
Method of sealing strata off ..
Pump: Manufacturer's Name Type.
II P. Pump intake depth:_R. Designed floss rate gym
Water Levels: Land-surface elesation above mean sea level 191 ft
Stick-up of top of well casing 1 ft.above ground surface
Static water level 77 ft.below top of well casing Date 8/3/23
Artesian pressure lbs per square inch Date
Artesian water is controlled by (cap.sake.etc)
_ I
Well Tests:
Was a pumping test performed" Pt No 0 Yes bs w bum"
Yield gpm with ft.drawdown after hrs
Yield gpm with ft.draw-down alter his
Yield gpm with ti.drawdown after has
Recovery data(time=zero when pump is turned off- water level measured from well
top to water level)
Time Water level Time Water l.evel Time Water I evel
Date of pumping test -
Hailer test gpm with_ft draw down after his
Air test 18 gpm with stem set at 100 ft for 1 hrs - Date 8/3/23 - - -
Artesian flow Fpm
Temperature of water 49 "F Was a chemical analysis made? ❑Yes O Nu Start Date 8/3/23 Completed Date 8/3/23
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
3 Driller O Trainee 0 PE-Prin Name Josh Koepp� Drillingtn Copam Arcadia Drilling Inc.
Signature Address PO Box 1790
License No.2874 Cm,State,Lip Shelton,WA 98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No ARCADDI098K1 Date 8/3/23
ECY 050-1-20(Rev 09/I8) l(sou need this document in an alternate format.please call the fluter Resources Program at 360-,f07-6872.
Persons with hearing loss can call 711 for ll'shingto n Relay Service. Persons with a speech disability can call 877-833-6341.
WATER
MANAGEMENT
MO. LABORATORIES a tic.
MOM i ell I Mb TODOMIL,VdA 10104
Date Sample Coiterged Time Sample County
Collected
'Jr 1-)- 7-3 1_: 111y(7,, nitti&viks1
Mar boy Yost
Type of Water System(check only one box)
CI Group A 0 Group 13
Group A and Gulp B Systems-Provine lom Water wiles Inventory(WFI):
System Nasne.FmrA 4/1-24),
ConkadPemom adia Drilling, Inc
Day Placa):( 3 60) 4 2 6-3 3 9 5 Cell Phone:( )
Email Eve.Phone:( )
Sind results (Print fit name.address and lie cak)
Arcadia
PO Box 1790
Shelton, VA 98564-
Sonde coleded by(name): 5kaci
Sppotic location Ware sample colleded: Special insbudons or comedic
*BP pow
HIrt FM to% s141.0
ilfrade.t.for.n*31 theNigli
1.0 Routine DIsbibution Sample(MP) 2.0 Repeat Sample(MP)
Chlorinate&Yes__No deo daltrion system air trod.cod*
Unsollelodoni routine Mb umber
Chionne Residual:Total Free_
—- —
3.Ground Water Rule Source Sample
Unsoldering routine collsctddr
IS I I I
Chlorineled Yes No
0 Triggered(AR) Chlorine Residua*Trild—Free_
Assessrrent(A/P)
4.Surface or Gva Ravr Source Water Sample(Enumeration)
ISI I
! E cod CI Fecal Famed Yes ko
5. Sands Colocted bdorldadoo On
0014f1: 00(#01#1004.3
UouNstoctoey Total CollfOrm Present and afisfactOry
1 CI Emil present Ecol absent
1 Sededd puler IWO:Told Cellkere___1100rit E.coli 1100m1.
tiOard. HPC /I mL
•
Required: CI Thr D Sample tr30 old
o SaMISIV01111ne 0 Damaged Container
Lab Reference NumberP
nnt 1(..) p.45 (4)-
**Taipc-. p Mdiod Codr.
L3N2-313
Dim Reported to DOK UaeOdy. AA004R
DOH Loosonplao
089 5SIL
.Ipacteeltisplicalosinaseenailemalcsib31.525021111101)Yanq
IVA NM Ow entdralleoz am>dais or.Mt as nnAlrb-as.A.v..
2200612 MASON CO WA
Return To 06/09/2023 02:50 PM NOTCE
YckY1C5m:\ z ec Fee: $204.50 Pages: 2
GZ 6 III II I
i 3` w Cora #c
W A . `-k
Grantor(s): (1).EY i5T 3. GonciCet , (2) VIC1YlejCa Medina fri-
Grantee(s): (1) PUBLIC
Legal Description (1) S 1/,�. t,1r± SE AP T2 t S+gi�VEY a-04. 5-1 lq` 3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) _J 0 Z- i I -Q U 0 3 0
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: 950 gallons
Dated on this q day of 1 ,-,S)C , 20 L 5.
Signature of.Grantor(s):
(1) . /ti' /./�W , (2) '
State of Washington
4 County of Mason
I
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I, the undersigned, a N4lotary Public in and for the above named County and State, do hereby
certify that on this 9 day of I1\-`:rj:5\s , 203 ,
vv\c a rev. n `'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.
Notary Public in and for the State of Washington,
\> \Ssion F•
oo• ,30 2��j residing at 1'l�\C;'�.�
- (j NOTARY- • N'
O..4alb - My commission expires: ')° D-` 3 ,
�n PUBLIC c):FA O
9) se Nmb?0 V
:c .
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