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Home My WebLink AboutWAT2023-071 - WAT Application - 7/18/2023 WAT Z023 - ob17 l treet �� MASON COUNTY4 Shelton, 6 8584 WA 98584 3 Shelton:360-427-9670,Ext.400 _ .►>. COMMUNITY SERVICES Belfair:360-275-4467,Ext.400 � ; .> Building,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/ rcel Identification Name on Applicant: YlC.t, L& iJ.e 14J Date: 743 - 2 6 23 Mailing Address: 31e, E 61rep.nU 1 ao kcal I Phone: 3La0 • 250 • 17N, Parcel Number: 3213'--f- `-i I— ljnn'—}'0 3'Sh,e _ W-4 Gi SSS 4 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit B Id 2023 -OCgI ED connections) ❑ Division of land: ill Individual water source(one connection), #of Parcels? SPL yf Well 0 Boundary line adjustment 0 Spring/surface water ❑ 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. J:\EH Forms\Drinking Water Revised 4/272021 Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ 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 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 This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 s CA'ag SEP 10 2023 RECEIVED WATER WELL REPORT Notiec of n a a ' 52416 ECOLOGY Unique Ecology Well II)Tag No.BPN043 lap,-id Work: . G�--i C N otuiithon Site Well Name(if more than one welly E Decommission t. Origiv.al installation N(II No Water Right Permit Certificate No. Proposed t'w: aL'DourNie 0 InJusirut =\huticipil Property Owner Name Patrick Walters 0 Ikssatenng 0 Irrigation LI Test Well __Other Well Street Address 370 E Greenview ("uoctruction Type: Aleth d: "S1 New well C Alteration Driven C.idled C Cable Tool City Shelton County Mason ❑Deepening 3 Other =Dug Lr Air- C Mud-Rusin Tar Parcel No. 32134-41-00040 Dlmrnslons: Diameter of boring 6 in.to 140 II Was a s anance appnned for this well? a Yc. C No Depth of cdunpktsst well 138 fl. If yes.what was the a:triance!Or? (oosnvctloa Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread C i 6 in. 2 132 25 in. M 1 O •I i L Location(see instructions on page 2): C WWM or D EWM C I C in. _ _ in. ❑ i ❑ U 1 ❑ NE i/4;of the SE ',;Section 34 Ti'tt nship 21 N Range 3 C I C in. in. :I l ❑ 0 10 C I -t in. in. _] ; O ❑ 1 O Latitude(Example:47.12345)47.26477 Longitude(Example:-12_1).l_3451 123.03983 Perforations: 0 Ye. ?No Type of perforator used No of perforations_ Sae of perforations an by m Driller's Log/Construction or Decommission Procedure Forriutasn Describe by soled.character.cue of material and sinrclure,and the kind and Perfiiratcd from tl.to_II.below ground rurfaee nature of the material to each layer penetrated.ctit at Icasl one entry Ibr each change of Screens: G Yes C No E IC-Packer ' Depth 131 it iuf'niunon Use additional sheets if necessary. 1 \ianutadnrer's Nanic JOHNSON Material Front To liar STAINLESS Mom' CLAY LOAM GRAVEL 0 2 Ds:nwler 5 in Skit cue 16 in..nmm 133 it.to 138 tl Diameter_ in Skit sire in from_It to_IL GRAVEL SAND CLAY 2 8 BROWN CLAY GRAVEL 8 36 SandiIllter pack:C Yes E No Sue of pack material in. GRAVEL CLAY SAND 36 83 Materials placed limn II.to 11. LIGHT BROWN CLAY SAND 83 101 Surface Sul: AlYes ❑No To%tat depth"2 fl. GRAY CLAY STIFF SAND 101 126 c Material toad in seal 318 BENTONITE CHIP Did any strata contain namable water'? _-Yes ::No FINE DARK GRAY SAND_WB 126 131 Type of water'.' tkptti of strata STIFF GRAY CLAY SAND GRAEL 135 138 Method of sealing strata off STIFF GRAY CLAY GRAVEL 135 138 GRAEL SAND WB 138 140 Pump: Manufacturer',Nate 1 ype. II P fungi intake depth:_Ii Designed Iloc rate. win - Water I.es eh: Land-surface elcaation mood mean sea level_II — Stick-up of top of nett casing 2 fl above ground citrtace ----—....--- Static water escl 94 fl_below lop of well casing [late 08/29/2023 -'.. Artesian pressure_Ihe_per suture inch Date Artesian water Is controlled by (car.sakc.etc 7 Well Test: -- Was a pumputg test perfiirmcd:' Lr No 0 Yes t=' by whom' Yield gpm wah_8.drasd'wn after_hrs. — Yield gam with fl drawdown aflcr hr. Yield _hint wall_Il drasadown alter_hr. Recoscry data titnie repo when pump is turned off water kaet measured Instil well top to water Icac11 Tam Water Level lime Water Level Tune Water Level Date of pumping test Bailer test_gpm with_II.drawdown atter_his L Au test 30 gpin with star set at 131 ft.for 8 hrs t Me - 911023 Artesian flow_gpm J Temperature of water ^F Was achernaal analysis mink"! 0 Yes t:No Start Date 08/24/2023 Completed Date 08/29/2023 %%ELL 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 an true to my best knowledge and belief. Driller' rands:_._I'L Print Name ROBERT LAYMON Drilling Company ADVANCED DRILLING LLC Signature Address 11530 SCHOOL LAND RD SW License No.2588 City.State.Zip ROCHESTER WA 98579 IF TRAINEE:Sptnsor's License No. Contractor's Sptatsur s Signature Registration Nds.ADVANDL804DL Datc09/09l2023 ECti'050-1.201 Rev IN,191/%tree ire a•d dos doriunr,rt sir in:alternate format please cull the Water Resonra•a'g Program at 360-407.6872. Petition with hoarii1g ling rem call 71l for Iliahug_'ioit RAW Soiree. l'er'n,tt rend II speech rhsnhihn emir call 877413.6341. 4 SZx 1 Vanguard Laboratory 2635 Parkmont Lane SW '' i�a Olympia,WA 98502 �', p.�,. ymP 360.967.7010 VANGUAR A. Report of Laboratory Analysis LABORATORY Collected by: Ackley Pump Service Matrix Drinking Water 1 360-827-2309 Laboratory ID: V230913-14 Sampling Address: Date Sampled: 9/13/23 13:30 370 E Greenview Date Received:9/13/23 16:05 Shelton,WA 98584 Date Reported:9/15/2023 1 Sample ID: 370 E Greenview Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V230913-14 Analyst:VJ Coliform,Total Negative I I MPN/I0O ml, I 9/13/23 17:13 E.coli Negative I I MPN/100 mL 1 9/13/23 17:13 4 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Robert Smalling,Chemist on 09/15/2023 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 09/15/2023 DF:Dilution Factor "••- 17025:2017 a: iceaeurren Page 1 of I MCL:Maximum Contaminant Level i`�� 1AIaTo v. Samples were recieved in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com - 2199663 MASON CO WA 07/18/2023 09:45 AM NOTCE PRTRICK WALTERS N188851 Rec Fee $204.50 Pages 2 �IIVII��II��I��IIIV I IIIIII IIII IIII IIIII IIIII Vlll I��IIIII IIV IIV�II� Ref rn To M7-r/ce &,1 C�1?k 37.) 6, cE,) v/Fri 4/11 5H5670A) /i14 9$5 Grantor(s): (1) lcr' "- 61- 'J , (2) Grantee(s): (1) PUBLIC Legal Description (1) In 1/� 1'llvJ� v c /'-I SE% 5 53/•139 .S3 -/ �3 (Abbreviated form:i.e. lot, block, plat or section, township, range) 2.Assessor's Tax Parcel: (1) / ( 3 / "I -. I - d 0 Q `I () 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: 144 Maximum Annual Average Gallons Per Day: 556 gallons Dated on this IT day of ( , 20Z3 . Signature of Grantor(s): () Q 4 fff , (2) State of ashington ) County of Mason ) I Page 1 of 2 4 I, the undersigned, a Notary Public in nd for the above named County and State, do hereby c ify that on this L t day of , 20 2 Wet{Ar5 pers nally appeared before me, who is known to be signer of the above instrument, and acknowledged • .t he (she) (they) signed it. GIVEN under my hand and official seal the day a d y:- last alp've ritten. 4,, d. . A Nota I Public in and •the Sta - of ,ashington, residing at My commission expires: ir 11 OVO S� PATRICIA KINNEY NOTARY PUBLIC#21012508 STATE OF WASHINGTON COMMISSION EXPIRES MARCH 4, 2025 • Page 2 of 2