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HomeMy WebLinkAboutWAT2023-00220 - WAT Application - 8/10/2023 WAT 202 - [ ol9,0 415 N.6th Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 &Mng.Planning.Environmental Health.CommunityHealth 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: ) I�� Kru�eV" Date: CZ,) 10)25 Mailing Address: 1325 W1 world Phone: � �► 3319a CPO 3 Z y Parcel Number: 32.02 —10— 00030 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more X Building permit -id 2023 001' connections) ❑ Division of land: 'g Individual water source (one connection), #of Parcels? SPL 131 Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 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) 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. ❑ 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. J: Ell Forms Drinkinm Water Revised 4/27/2021 Individual Water Well Water well report(attached to application). Depth ft. A Well capacity Test(attached to application) `� 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). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14) 15 16 22 Water use or limitation recorded N/A Yes � , 151 Well Drilled Date 23 Individual Spring/Surface Water ❑ WDOE permit(attach to application) 0 Method of disinfection 0 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 61-17)nrZ This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 gall WATER WELL REPORT CURRENT Notice of Intent No.WE5127o Original&I"copy-Ecology,Y"copy- eer,3'a espy-driller Weer, li .0 Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. BPL78I ID Construction Water Right Permit No.N/A 1 [] Decommission ORIGINAL INSTALLATION Notice Property Owner Name Tyson KnBa of Intent Number Well Street Address 1981 SE Binns Swiger Loop Rd. PROPOSED USE: El Domestic 0 Industrial ❑ Municipal City Shelton County Mason 0 DeWater ❑Irrigation 0 Test Well 0 Other Inration SE l/4-1/4 SE I/4 Sec 27 Twn20 R3W 1" Eleuele TYPE OF WORK: Owner's number of well(if more than onc) 'm one wNM l�J New well 0 Reconditioned Method ['Dug ❑Bored 0 Driven Lat/LongLat Deg47 Lat Min/Sec I8844 El Deepened ❑Cable ❑Rotary p Jetted (s,t,r DIMENSIONS: Diameter of well 6 inches,dulled 75 ft Still REQUIRED) Long Deg -123 Long Min/Sec 0362a Depth of completed well 75 _ __ ft CO\sTRI:clloi DETAILS Tax Parcel No.N/A Casing ®Welded 6 - _Linn Darn from •2 ft to-75_ ft Installed: Linn mstaltcd Dian from _-ft to ft CONSTRUCTION OR DECOMMISSION PROCEDURE 8 Threaded " Diam front ft to ft Perforations: ❑Yes ©No Formation' Describe by color,character,size of materiel and structure,and the kind and nature of the material in each stratum penetrated,with at least one catty for cacti change of Type of perforator used taformalicm (L'SE ADDITIONAL SHEETS IF NECESSARY.) SIZE of pats in by in and no.of pars from_ft to_ft MATERIAL FROM TO Screens: 0 Yes ®No 0 K-Pac Location — Tan silty sand and gravel,medium 0 60 Manufacturer's Name Grey silt 60 70 Type Model No Tan sand,small,23 gpm 70 75 f)ivot Slot aims from ft to_ ft Diem a' Slot we from ft to ft Grave l/Fater packed:El Yes ®No ❑Size of gravel/sand Materials placed from ft to ft Surface Seal: ✓❑Yes ❑No To what depth?18 R Material used in seal bollard*dile _ Did any strata contain unusable water? ❑Yes lid No Type of water? .. Depth astral*_ Method of sealing strata off -_. _._ PUMP: Manufacturers Name Type. lIP t WATER LEVELS: Land-surface elevation above mean sea level 11115__- ft Static level 47S ft below top of well Date 7/ISn't....__. Aticsian pressure -_ lbs per square inds Date Artesiaa water is controlled by_ - (cap,valve,etc) WELL TESTS: Diawdown is amount vester level is lowered below static level Was a puny test made?l]Yes 0 No If yes,by whom? Trent Burrell Yield:18 pal/men.with7.62 ft drawdown a[ta4 hrs Yield: gal Men with ft,drawdown after __ _be' Yield. gal/min with ft drawdown after hrs Recovery data(time taken as rero when pump turned of])(ware,level measured from well top to voter level) Time Water Level Time Water level Time Water Level • fig_ 54.79 1331 49...87 —_ 5175 JSIL 49_47 1330 50.54 -- — Date of test 3/15/23 - Bailer test gal/,run.with ft drawdown afte. lrs Joh k Airiest gal./min with stem set at ft fort hrs Artesian flow _ g p in Date _ Temperature of wales 54 Was a chemical analysts made? 123 Yes 0 No I Start Date 3/13/23 Completed Data 3/15/23 WELL CONSTRUCTION CERTIFICATION: l 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 0 Trainee Name.;row!Jacob Hansen _- finning Company Tacoma Pump&Drilling Co.Inc. Dnller/IingineerrTtamcc Signature __ Address 30316 Mountain Highway Driller or trainee License No 3180 City.State,Zip Graham,WA 98338 If TRAINEE, Contractor's Draer's Lk-eased No. _- __ Registratan No. TACOMPD203PF Date 3/16,23 Driller's Signature_ Leo.ogy is an.Equal Opportunity Employe' ECY 050-I-20(Res 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report. I SPECTRA Laboratories ...Where experience matters 22-21 Ross Way • Tacoma, WA 98421 • (253) 272-4850 • Fax (253) 572-9838 • www.spectra-lab.com Analytical Report Tacoma Pump&Drilling Project 1981 Binns Swiger Lp Rd,98584 30316 Mountain Hwy PO Number Graham,WA 98338 Date Received 03/15/2023 Client ID: Well 1 of 2 Lab No: 305808-02 Sample Date:03/15/23 13:30 Analyte Method Result Units PQL Qualifiers Analysis Date Analyst Total Coliform SM 9223 B Absent Present/Absen — — 3/16/2023 010 E.coli SM 9223 B Absent PresentlAbsen -- — 3/16/2023 010 Client ID: Well 2 of 2 Lab No: 305808-03 Sample Date:03/15/23 13:30 Analyte Method Result Units PQL Qualifiers Analysis Date Analyst Total Coliform SM 9223 B Absent Present/Absen — — 3/16/2023 010 E.coli SM 9223 B Absent Present/Absen — — 3/16/2023 010 010=Analyzed by Spectra Laboratories-Kitsap(Poulsbo).See complete report provided. Lab Qualifiers Comments: This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 03/28/2023 Page 2 of 2 2200841 MASON CO WA 08/16/2023 09.26 AM NOTCE KRUGER #189799 Rec Fee: $204.50 Pages: 2 Return To 111111I 1111 II III IIIIIII 111111 IIII I I II II HI IIIIIII II III I IIMI I II 9 n I4i rLX.e.1 - I 2__5 InJ its[YA +?L h,2_,Li-on ,0, 96514+ Grantor(s): (1) iA &iiqeV , (2) Grantee(s): (1) PUBLIC . Legal Description (1)'j L;3 6r3.-vu.f Iie1 Ex 1'T I L ;nti ELy of L&)Ly 4d (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 3 �► L.) .4 , - 7 - t O . 3 0 di )710 / 3 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: I Maximum Annual Average Gallons Per Day: 1�d gallons Dated on this 1 t day of Aclo psi , 202s'. Signat re of Grantor(s): (1) XL , (2) State o 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 (ice day of Akyu).1 , 20��, �yson T trvg.e Y 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 abovwritten. �a�uii�1111gi Notary Public in and for the State of Washington, ```��• GrI��• ,���, residing at W\GL /' `� LA s ` ' NOTApy My commission expires: I 1 yy(2 Gj 12 U �►�! ' PUBL3G • s • \dr* MMA�`�ipK"` Page 2 of 2