HomeMy WebLinkAboutWAT2022-00163 - WAT Application - 6/13/2022 WAT CO•
' 47 ,` MASON COUNTY
41./,,
• COMMUNITY SERVICES
:'/ Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400/11,
FAX(360)427-7787
Application for Determination of Water Adequacy 67
Instructions S�i yl3
1. Complete Part 1. No determination can be made until Part 1 is fully completed. •'9/ 1'?)
2. Complete only the portion of Part 2 applying to the type of water connection utilized. 0/.
3. Submit completed application, with any required attachments for review. S)r
4. An approved building site plan must accompany this application. 0
Part 1: Applicant/ Parcel Identification
Name on Applicant: Empire Home Construction Date: 06/01/2022
Mailing Address: POB 241, Kelso, WA 98626 Phone:253-753-1530
Parcel Number: 120303190084
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more El Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
El Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
❑ 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. J /J �"}�3 '�Q 31
Part 2: Water Connection Information �
Complete the section appropriate for the type of water connection being evaluated: ENONME' `TAL
Public Water System .HEALTH
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.
Signature of Water System Manager Date 06/01/2022
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
ater well report (attached to application). Depth 2 -t_v ft.
Well capacity Test (attached to application) \c- 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).
�� Z2o2 5 -POO �1
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planninq 14 151__1 161_j 24J
Water use or limitation recorded N/A Yes'
Well Drilled Date
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:
Environ. Health: Date l LTh
2 of
CSD Director: Date
i5eer q 1fcicA'( mar 1 wI'1 h vp d o eel iveti I y
l'nfcifiliciiim. P) 1 6'' 2- SEp2 ,1, 7
WATER WELL REPORT ' ' DEPARTMENT OF Notice of Intent No. RFC p
. ' 1 E CC)�.O CIY Unique Ecology Well ID'fag No.
Type
,e of Work::
'�-1 State of Washington
U Construction Site Well Name(if more than one well):
L] Dcconunission Original installation NOI No. \Voter Right PcnniUCcttilicate No.
Proposed Use: tat Domestic LI Industrial U htuniciptl --�--- Property Owi1Cf Nttttte
U Dewateriug El Irrigation I1 Test Well U Other Well Street Address 601 Construction Type: Mretl'n'l' CityStratton County Mason
t New well U Alteration 0 Driven [)Jetted (al Cnble'I'ool -- --
❑Deepening U Diller _ 0 Dog n Air- n Mnd•Rotar' Tax Pored No. 120303190083
Dhneusimst Diameter of boring 6 in.,to 235 a. Was is variance approved for this well? n Ycs El No
Depth of comptcled well 240 A.
If yes,what\vas the variance for?
Construction Delnils: Wall
Casing Liner Diameter front To Thickness Steel PVC Welded Thread
Li) I (:I 0 in. +1 235 1/4 in. D 1 0 U I id Location(sec instructions on page 2): U\VWM or bd EWM
❑ 1 D in. _ in. D I D ❑ I U sw ''/r•%of the ne ''/r;Section 30 Township 20n Range 1\v
❑ I (3 in. _ _ I ❑ I U
n 1 fl in, in. D I D D I Li Latitude(Example:47.12345) _—
l.ongitude(Example:-120.12345) -- -
I'erforollons: U Yes DO No Type of perforator used
llriller's Log/Construction or Decommission Procedure
No.of perforationsrations Size of perforations tar fn.by in. Fonuation:Describe by color,character,size of material and stricture,nod the kind and
Perforated from A.to ft below ground surface nature of the material in each layer penetrated,will,nt least one entry for each change of
Screens: O Yes n No 1')K-Packer t ) Depth 233 n. information. Use additional sheets if necessary.
Manufacturer's Nauw alloy Material from To
Type stainless Model No. 0 3
Ditnuctcr 5 in. Slot size 12 in.from brown sandy loam 235 g,l0 240 �, 18
Diameter in. Slot size in.front 3 fl.to ft. brown Iill 3 178
brown sand w/occasional gravels 18
Smtdrniuer pock:0 Yes W No Size of pack material in. line to mod sand brown water bearing 178 240
Materials placed from _____ft.to 0.
Surface Seal: OO Yes n No To what depth? 10 fl.
Material used in seal bentonite chips —
Did any strain contain unusable sealer? ❑Yes O No --------- ---- --
T)ye o C%Vale rt Depth of strata
Method of sealing strata o11 -
Pump: Manufacturer's Name goulds Typo: sub
I LP. 2 Pump intake depth:225 0. Designed flow rote: 18 ppm
Writer Levels: Land-surface elevation above mean sea level __A.
Stick-up of top of well casing_._. n.above ground surface
Static water level 170 ft.below top of well casing Date
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,salve,etc.) -__ - --
Well'tests:
Was a pumping test performed? E No I Yes : by wham?
Yield__ ppm with A.showdown after_hrs. _--..-
Yield gpm with__ft.showdown r ter his. -
Yield gpnt with„ft.drawdown after firs.
Recovery data(lime-zero when pump is wrrKd off-water level nicas,acd front well
top to water level)
Time Water Level Time Water Level Tines Water Level
Date of pumping test - '
Bailer test 15 ppm with 11 ft.drawdown after 4 hrs.
Air test gpuu with ALCM set n1 ft.for hrs. Date
Artesian flow gun
Temperature or water °F Was a chemical analysis made? 0 Yes (01 No Start Dale 10-12-2022 Completed Dale 11.18.2022
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington\wit
conslntction standards.Materials used and the information repotted above arc true to my best knowledge and belief.
D Driller 0 Trainee 0 PE-Print Name _ Drilling Company KNAPP DRILLING INC.
Signature P(�(yt!L1Z4- A'114 p��A' Address 50 east lesasca Dr.
License No. 1708 v v4 City,State,Zip Shelton Wa.98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature
Registration No.KNAPPBI952B1 Date 11/15/2022
ECY 050-1-20(Rev 03119)/f)'ou need this document in an alternate format,please call the water Resources Program at 360-407-6872.
Persons with!rearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-634!.
Pq2o
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Wendy Mathews
From: Tiffany <Tiffany@olypump.com>
Sent: Thursday, September 21, 2023 2:22 PM S�P
To: Scott.malone@ecy.wa.gov 2 ?023
Cc: Mike Brewer;Tiffany; Wendy Mathews RE
Subject: Knapp Drilling - 605 East Inspiration Way, Shelton, WA 985 CE/1D
Attachments: Well Log.pdf;Wellhead Photo.jpg
Importance: High
Caution: External Email Warning! This email has originated from outside of the Mason County Network. Do not
click links or open attachments unless you recognize the sender, are expecting the email, and know the content is
safe. If a link sends you to a website where you are asked to validate using your Account and Password, DO NOT DO
SO! Instead, report the incident.
Hi Scott,
Attached is the well log you and Mike discussed today.
The address is 605 East Inspiration Way, Shelton, WA 98584
Coordinates: 47.191614, -122.855554
Well ID Tag No. BPU397
NO1: WE49664
Owner: Empire Home Construction LLC
Please let us know if you need anything else. Thank you!
Tiffany Karpavicius
Director of Operations and Business Development
( AME RICAN
PUMPANUI1RIL1- If, U
Phone:360-754-7867
Mobile:360-216-6389
1
. 2199606 MASON CO WA
07/17/2023 12.03 PM NOTCE
EMPIRE 11188809 Rec Fee: $204 50 Pages 2
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Grantor(s): (1) Ergx Q:ra- u-. Cc"s , (2)
Grantee(s): (1) PUBLIC L c,V
Legal Description (1) I.o . - 3 o Sr 5 ? # gcc ?r N TR '8 5 2 /1 y!
( viate an:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: ( 3_ O - - Y .iz a Z_ 3
a3 � 31 9 0G3 `-t
TITLE NOTIFI O F WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the under ned g n or(s), hereby place this notice on record that the described real
estate situated in son ( unty, State of Washington is subject to water use restrictions and
conditions s t trf on State Senate Bill 6091 and Mason County Code 6.68. These
restriction nd car< ions are based on location of property and/or Water Resource
Invento re r W A.
W
nnual Average Gallons Per Day: 15 O gallons
0 "�1;
9 . .n this i 3 day of -V'I"f , 20 �3.
. nature of Grantor(s):
(1) ,u, 4) Fi/a A , (2)
State of Washington )
County of fdMse4. t 0 PI i fi- )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named\\Gounty and State, do hereby
certify that on this 13* day of litly , 20,13 , \\
DcwldL.tpVa 1�MG Y tY personally appeareciree, who is known to be
signer of the above instrument, and acknowledged that he) they) signed it.
14,)GIVEN under my hand and official seal the day and, :be, e w iin.
DEENA L DOLBEY Not= Publi •n and for th'• State of Washington,
NOTARY PUBLIC i• •• _ Qn,view
STATE OF WASHINGTON j ola5�a0
COMMISSION NUMBER 74363 My c mission expires: 13
COMMISSION EXPIRES OCT 25,2023
N\:D
0
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