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Home My WebLink AboutWAT2023-00211 - WAT Application - 7/27/2023 • WATAca3 - OO-l/ MASON COUNTY COMMUNITY SERVICES °., Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269 ext 400 FAX(360)427-7787 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: Robert Flath Date: 7/27/23 Mailing Address: 113 E Terrace Dr Belfair, WA Phone: 360-277-7206 Parcel Number: 32134-31-00040 Type of Water System Reason for Application❑ Public/Community Water System (2 or more El Building permit ,LD .o.3-06'nd S'4 connections) 0 Division of land: NV Individual water source (one connection), #of Parcels? SPL EY Well 0 Boundary line adjustment Spring/surface water ❑ 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. O0Dl 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: 1101AL (write"none"for two-party) FiZ,I am the manager of this water system. The water system has been approved for .2.— 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 Q�Date V 1 s (Z�j 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 Water well report(attached to application). Depth C 99 ft. Well capacity Test(attached to application) c-0 qpm 2 gjpd. 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. i Y Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 1471 150 160 22E] Water use or limitation recorded N/A Yesn741 Well Drilled Date 5/25/23 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: 12-3 Environ. Health: Date CSD Director: Date 2°' WATER WELL REPORT ,_,,,,WIN DEPARTMENT Of Notice of Intent No. WE51729 _-- ECOLOGY Unique Ecology Well ID Tag No. BPF009 1 Type of Work: State of Washington O Construction Site Well Name(if more than one well): 4t 0 Decommission v Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: !t Domestic 0 Industrial 0 Municipal Property Owner Name Prime Location&Situations LLC 0 Dewatcring 0 Irrigation 0 Test Well 0 Other z Well Street Address 1161 E Mason Lake Rd Construction Type: Method: E New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug GO Air- 0 Mud-Rotary Tar Parcel No. 321343100050 d Dimensions: Diameter of boring 6 in.,to 99 ft. Depth of completed well 99 ft. Was a variance approved for this well? 0 Yes O No Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread ® I ❑ 6 in. 0 99 .025 in. 13 1 0 El 1 0 Location(see instructions on page 2): £WWM or❑EWM ❑ 1 0 in. _ in. ❑ I ❑ 0 10 NW ,A-Y.of the NW V.;Section 34 Township 21N Range 3W I D 1 ❑ in. in ❑ 1 ❑ ❑ 1 ❑ ❑ 1 ❑ in. in. ❑ 1 ❑ ❑ 1 D Latitude(Example:47 12345) 47.262621 Longitude(Example:-120.12345) -123.052352 Perforations: 0 Yes Gil No Type of perforator used i Driller's Log/Construction or Decommission Procedure For"1 No.of perforations Size of perforations is by to B/ Perforated from ft.to_fl.below ground surface natur oft Describe by color,character,size of material andentry structure,mud the kind and nature the material in each layer penetrated,with at least one ent for each change of Screens: 0 Yes E No 0 K-Packer '--~' Depth fl. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size_in.from ft.to fj. Brown sandy loam 0 1 Diameter Slot size in.from ft.to ft Brown silty sand and gravel 1 13 Sand/Filter pack:0 Yes il No Size of pack material in Multicolored gravel,silt 13 18 iMaterials placed from ft.to ft. Brown silty sand and gravel 18 31 Multicolored gravel,brown medium sand,loose 31 56 Surface Seal: E Yes 0 No To what depth? 19 fl. Multicolored gravel,brown medium to coarse 56 Material used in seal Bentonite Chips Did any strata contain unusable water'? 0 Yes IFJ No sand,loose,water 99 "Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type' H.P. Pump intake depth: ft. Designed flow rate. gpm Water Levels: [-and-surface elevation above mean sea level 242 fl. Stick-up of top of well casing 1.5 fl.above ground surface Static water level 37 ft.below top of well casing Date 5/25/23 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ®No 0 Yes CJ by whom? Yield gpm with_fl.drawdown after hrs Yield gpm with_ ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery dais(time=zero when pump is turned off-water level measured from well top to water level) Time Water Level Tune Water Level Time Water Level Date of pumping test Bailer test_gpm with ft drawdown after hrs. Air test 50 gpm with stem set at 80 ft.for 1_hrs. Date 5/25/23 Artesian flow gpm Temperature of water 49 °F Was a chemical analy sis ysis made? 0 Yes ®No Start Date 5/25/23 Completed Date 5/25/23 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. 1J Driller 0 Trainee 0 PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature �'/ Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's L cease No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/25/23 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6871. Persons with hearing loss can call 71 1 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. • Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 ysxaaMa 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 06/06/2023 ; 0 E)AM Mason • 1bnt Day Vex ---- - ----- vM Type of Water System(check only one box) ❑Group A ❑Group B SiOther PVT Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# system Name: Robert Flath Contact Person:Meta Eisele/Arcadia Drilling — — Day Phone:(360 )426-3395 Cell Phone:( ) Email:arteta@arcadiadrilling.com Eve.Phone.( ) Send results to(Print tua name,addleas and zip code or e-mail) Meta Eisele/Arcadia Drilling arleta@arcadladrilling.com • SAMPLE INFORMATION Sample collected by(name)'M a X Specific location where sample collected: Special instructions or comments: #BPF009 1161 E Mason Lk Rd.Shelton Type of Sample(select only one type of ssRlple from types 1 through 5 below) 1.0 Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A/P) Chlonnated:Yes No (from distribution system atter unsat routine) Unsatisfactory routine lab number. Chlonne Residual.Total__. Free_ 3 Ground Water Rule Source Sample ISI Unsatisfactory routine collect date: sI r l Chlorinated:Yes No_ ❑Triggered(A/P) Chlorine Residual:Total Free___ ❑Assessment (AR) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑E co& 0 Fecal Fasted rea_._No ®Sample Collected for Information Only: LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coldomi Present and ®Satisfactory ❑E coir present ❑E coil absent Bacterial Density Results:Total Conform.__ /100ml. Ecoli 1100m1. Fecal Col,form /100ml. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ Dat Rer2elved:3 j Z3O m O 7-9 C7/t I(� 30 Receipt Temp Ca' Method Code: SM 9223E Dale Reported to DOH i Lab Use Orly:DOH LabSample5 285— Son Fart.1011.319(ar.cs.06,17)•If you nod iw MOM.n n o rise•rarrt.;mi eoo s23012?(roo rTC as 711) far AM ear penman!srWYawr to iwpm?.ergraa 2200793 Mason County WA 08/14/2023 02:56:26 PM NOTCE eRecorded #189756 RecFee: $203.50 Pages: 1 F LATH Return to: Robert Ftath ?jL,p a-02-3' 00954 113 E Terrace Dr Betfair, WA 98528 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) I(We),the undersigned grantor(s),hereby place this notice on record that the following described real estate situated in Mason County,State of Washington;to wit: _ OR 3 21 34 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 3 2 1 3 4 - 3 _t - _0_ 0 0 4 (0 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 Dated on this day of ASA ,20 , Signature of Grantor(s): 12:21W.4.0044.0* Printed name of Grantor(s): l♦0 ke-t-.I-1-- Raft,t, . Grantee: Public State of Washington County of Mason ) I,the undersigned,a Notary Public in and for the ye named County and State,do hereby certify that on this 1 day of trt. .20 7-1 3 , 1.4 c'1 L personally appeared before me,who is known to be the signer of the above instrument,and acknowl at he(3! )signed it Given,under my hand and official seal the day and year last a.. io,. "pp GttEGQRYA RUSSELL 41Fotary • S, • for the State of Washington, Notary Public t state of Washington ( Residing at lc� ,�►�•s • •...- Commission R 134076 My commission expires: r 14 ts3" My Comm. Expires Aug 14.2025 3 I