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Home My WebLink AboutWAT2023-00208 - WAT Application - 8/8/2023 W AT a o 2Ob ENVIRONME MASON COUNTY �A�TH COMMUNITY DEVELOPMENT RECEIVED Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, AUG - 8 2023 Shelton: (360)427-9670 ext 400 •: Belfair: (360) 754 44687xt 400 •:• Elma: (360)48222 5269 ext 4,OPder Street 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: �c�1Y1eS5 Date: < `-1 )2. 3 Mailing Address: (7U 9)(:)% 111t\ 1ZkAL c' VY.... Phone: 3(,Q()- (pctSc - 6-o(, Parcel Number: "2(&- 2-3a-W 3- ' l a4s256 Type of Water System Reason for Application 14 Public/Community Water System (2 or more A Building permit 303.3 connections) 0 Division of land: �V 0 Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water CI (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) 013( \-1 System box. LA' Part 2: Water Connection Information �" r Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Water Facility Inventory (WFI) Number: YlO`C1-42___ (write "none" for two-party) jid 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 5L 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 ' '7 (2L23 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 .6 Water well report(attached to application). Depth \--iq ft. Well capacity Test (attached to application) 15— gpm 7'`a00 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. y( Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 17(151 I16n 22n Water use or limitation recorded N/A 0 Yes Pin Well Drilled Date I 1(k(�i2 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. Healtf Date ( 'I Z� CSD Director: Date 2 of 2 r /� Ef - .. �`, N�� FAL f rff;FIVED 1�I�an33 bbVQ HEALTH t',.1._' , - 8 13 6 WATER WELL REPORT .,_,:iL ;J DEPARTMENT OF Notice of Intent No. WE45713 II ECOLOGY Unique Ecology Well ID rag No. BNV867 Type of Work: 6111WII State of Washington O Construction Site Well Name(if more than one well). ❑ Decommission o Original installation NO!No. Water Right Permit/Certificate No. Proposed Use: O Domestic ❑Industrial 0 Municipal Property Owner Name Ben Jennings 0 Dewatering ❑Irrigation 0 Test Well 0 Other Well Street Address Mason Lake Rd Construction Type: Method: IE New well 0 Alteration 0 Driven ❑Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other ❑Dug ll Air- ❑Mud-Rotary Tax Parcel No. 32126-20-04000 Dimensions: Diameter of boring 6 in..to 179 ft Was a variance approved for this well? O Yes O No Depth of completed well 179 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To "thickness Steel PVC Welded Thread I 0 6 in. 0 174 0.25 in. I ❑ 0 I ❑ Location(see instructions on page 2): II WWM or 0 EWM ❑ I D in. _ in. 0 I D ❑ I ❑ SW '/,-1/4 of the NW 'Vat;Section 26 Township 21 N Range 3W O 1 0 in. _ _in. ❑ I ❑ ❑ I ❑ O I 0 in. in. ❑ I D ❑ 1 ❑ Latitude(Example:47.12345) 47.282828 N Longitude(Example:-120.12345) -123.031800 W Perforations: 0 Yes 0 No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to ti.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes 0 No Ill K-Packer rr Depth 173 li. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wlre Wrapped Model No. Diameter 5 Slot size.014 in from 174 a.to 179 a. Brown fine to medium sandy gravel,silt 0 Diameter Slot size in.from ft.to ft bound,tight,dry 74 Brown fine to medium sandy gravel,gray silt 74 Sand/Filter pack:❑Yes lil No Size of pack material in. Materials placed from a.to ftbinding,tight,dry 81 Black sharp gravel,gray clay binding,tight,dry 81 93 Surface Seal: it Yes 0 No To what depth? 19 a Brown medium to coarse sandy gravel,loose 93 Material used in seal Bentonite Chips Did any strata contain unusable water', 0 Yes E No silty ,;tot 111 Type of water? Depth of strata Brown gravelly medium sand,active,wet 111 133 Method of sealing strata oft" Heaving coarse brown sand 133 139 Gray silt,stiff,dry 139 154 Pump: Manufacturer's Name Type Gray silty brown fine sand,moist 154 157 H.P. Pump intake depth:_ft. Designed flow rate: gpm Gray clay,stiff,dry 157 172 Water Levels: Land-surface elevation above mean sea level 295 ft. Brown clay,stiff,dry 172 173 Stick-up of top of well casing 1 fl.above ground surface Static water level 75 ft.below top of well casing Date 7/26/22 Coarse sandy gravel to cobles,water 173 179 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,salve,etc.) Well Tests: Was a pumping test performed? El No 0 Yes , by whom? Yield gpm with ft.drawdown nacr hrs Yield gpm with II.drawdown after_hrs. Yield gpm with fi.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 Time Water Level Date of pumping test Bailer test gpm with fi drawdown after Ins. Air test 75 gpm with stem set at 160 ft.for 1 hrs Date 7/26/22 Artesian flow gpm _ Temperature of water 51 °F Was a chemical analysis made? 0 Ycs IC No Start Date 7/26/22 Completed Date 7/26/22 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 Driller 0 Trainee 0 PE—Print Name h ' Tr-- Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 7/26/22 ECY 050-1-20(Rev 09/I S) If you need this document in an attenuate formal,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call877.833-6341. QO3OQ% 7 2 NV1Rp NIENTA 1786 SE Mile Hill Drive RECEIVED 1 V i Port Orchard,WA 98366 _r , - SPECTRA Laboratories-Kitsap wmv.spectra-lab.com A U G — 8 2023 IL 1 EA 1 L.. � ,rr,,„perlence nallf (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM 615 W. Alder Street Date Sample Collected Time Sample County Collected 8 J 16 I 22 3 45 aua Mason Mont ear 'ro'roar. -- _-gJ PM Type of Water System(check only one box) ❑Group A ❑Group B DOther Group A and Group B Systems-Provide from Water Facilities Inventory(WFl): ID# _System Name: Ben Jennings Contact Person:Arleta ElselelArcadla Drilling Day Phone:360-426-3395 Cell Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send results to:(Print full name,address and zIp code or e-maiq arleta@arcadladrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name):Mason Specific location where sample collected: Special instructions or comments: Well Head#BNV867 East Mason Lk Rd,Shelton Type of Sample(check only one box) 1.❑Routine Distribution Sample 12.Repeat Sample(after unsat.routine) Chlorinated:Yes a No U I ❑Distribution System Chlorine Residual:Total Free_ Unsatisfactory routine lab number. 3.Source Ground Water Rule Sample —_ ISI I I Unsatisfactory routine collect date: 1 _1 I ❑Triggered Chlorinated:Yes❑ No❑ ❑Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample S I I ❑E.col/ decal-straw,GM.Springs.Fared Yes❑ tic 5.0 Sample Carected to Information Only: —LAB USE ONLY DRINKING WATER RESULTS LAB U ONLY • ❑Unsatisfactory Total Coliform Present and atisfactory ❑E.coli present ❑E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform 1100m1. E.cofr... 1100ml. Fecal Coliforrn _ .1 I. ` -IPC It ml. LablDNumber i • Vy, Method Code: Date and Time Incubated: SM 9223 B µH lr AUG 17 2027 Cate Analyzed: 2012 Date Reported COH tab-Samplee Lab Use Only: 225 .______ etOt rare 1.131319rdecte OviQ•Myan red hapAkskn In in almaheIamY arse 513.01 F?fosYrtt col71n. >hr Ma elm p.*.k a n.c.btre olenwr.dc anIena lrvreer ENVIRONMENTAL 2200573 MASON CO WA . 08/0 /2023 :22 PM Fi Li-,L H BEN JENNINGS2#189579NRecEFee: $204 50 Pages: 2 JI1ll IV III U1.IILIIJIIII I111111111111111111111111 III 11111 I I I II HE II II REU tu0.96 - UD 9q R turn To AUG - 8 2023 P.h 3P,vlr I n ..0 a Bo Y. 17 b15 W. Alder Street eI Cam;r Gvek .U6O7k . Grantor(s): (1) Zevx Sep.mi n S , (2) c1CS1(Cs- T.nr1i yls 1 Grantee(s): (1).PUBLIC Legal Description (1) LOT 1 OF SP #3156 AF #2189633 PTN OF W 1/2 W 1/2 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 32 1 2 6 23 9 4 0 0 1 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: 14 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this ` day of g , 20,23 . Signs rantor(s): State of Washington ) ICounty 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 8 day of 4‘.$06%.3s,-)k- , 20 Z3 , 'Ex2x•kntsicuss„ S- .SSic.w a't w*ncsspersonally 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. t 6t --------- KAELI E MCAULEY Notary Public N t ry Public in and for the State of Washington, State of Washington residing at 526 t J C12 tkv Shzi F i (-Oct License Number 22037380 My Commission Expires My commission expires: Jariv rti 20, 2027 January 20, 2027 Page 2 of 2