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HomeMy WebLinkAboutWAT2023-00206 - WAT Application - 7/27/2023 wAT3 — 0 1=11) 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 •S 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: 32134-31-00010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit Btbao,A3-OO' S3 connections) ❑ Division of land: [/ Individual water source (one connection), #of Parcels? SPL gWell ❑ Boundary line adjustment 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: /Lb$..C- (write"none"for two-party) J- I am the manager of this water system. The water system has been approved for services. There are presently o connection(s) in use. This will be the 1 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. �1 Signature of Water System Manager Date E.).;" ef !23 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 dirommomir Individual Water Well d Water well report (attached to application). Depth 99 ft. Well capacity Test (attached to application) gpm 7 C-° 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 1471 15E3 16=22= Water use or limitation recorded N/A Yes/I 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: Environ. Health: Y6Y/7 l) Date 12-612_e-- °f CSD Director: Date tom WATER WELL REPORT -:, ,µ. _ DEPARUMENI OF Notice of Intent No. wE51729 ECO LOGY Unique Ecology Well ID Tag No. BPF009 Type of Work: ap State of Washington El Construction Site Well Name(if more than one well): 0 Decommission r— Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: 0 Domestic 0 Industrial ❑Mwucipal Property Owner Name Prime Location&Situations LLC 0 Dewatering 0 Irrigation ❑Test Well ❑Other Well Street Address 1161 E Mason Lake Rd Construction Type: Method: O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 321343100050 Dimensions: Diameter of boring 6 in.,to 99 ft. Was a variance approved for this well? ID Yes No Depth of completed well 99 A. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter Front To Thickness Steel PVC Welded Thread I ❑ 6 in. 0 98 .025 in. 3 I 0 O 1 0 Location(see instructions on page 2): 51 WWM or❑EWM ❑ 1 0 in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ NW y,-yofthe NW A;Section 34 Township 21N Range 3W ❑ 1 ❑ in. _ in. ❑ I ❑ ❑ 1 ❑ ❑ 1 0 in. _ _ in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.262621 Longitude(Example:-120.12345) -123.052352 Perforations: 0 Yes 5il 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 ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature re of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes Ian No ❑K-Packer '-a Depth_ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size in.from ft.to_ft. Brown sandy loam 0 1 Diameter Slot size_in.from ft.to A Brown silty sand and gravel 1 13 Sand/Filter pack❑Yes GI No Size of pack material in. Multicolored gravel,silt 13 18 Materials placed from It to ft. Brown silty sand and gravel 18 31 Multicolored gravel,brown medium sand,loose 31 56 Surface Seal: ^it Yes ❑No To what depth? 19 ft. Multicolored gravel,brown medium to coarse 56 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes El No sand,loose,water 99 Type of water? Depth of strata Method of sealing strata oft' Pump: Manufacturer's Name Type' H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 242 ft. Stick-up of top of well casing 1_5 9.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? 0 No 0 Yes b by whom? Yield_ gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown alter hrs. Yield gpm with ft.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_ft.drawdown after hrs. Air test 50 gpm with stem set at 80 ft.for 1_hrs. I Date 5/25/23 Anesian flow gpm Temperature of water 49 °F Was a chemical analysis 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. E Driller 0 Trainee 0 PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature /6/P AAddress PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's L cense No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/25/23 ECY 050-1-20(Rev 09/I8) If you steed this document in an ahernate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 71 1 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. firs • I Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 yGH2O4Ajj 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 06/06/2023 3cwlea o" Mason ANrnF Oay Year -_._._ _____ PAYear Type of Water System(check only one box) ❑Group A ❑Group B ®Otter PVT Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# system Name: Robert Flath Contact Person:Arleta Eisele/Arcadle Drilling Day Phone:(360 )426-3395 Cell Phone:( ) Email:arletaCtarcadiadriNing.com Eve.Phone:( ) Send results to(Print lux name.address and*cede or e-mail) Arleta beck:Arcadia Drilling arleta@arcadiadriuing.com SAMPLE INFORMATION Sample collected by(name)Max Specific location where sample collected: ( Special instructions or comments: k8PF009 1161 E Mason Lk Rd.Shelton Typo of Sample(vied only ono type of ample ton type.1 Iwouph 5 below) 1.0 Routine Distribution Sample(AlP) 2.❑ Repeat Sample(AR) Chlorinated:Yes No (from distributionsystem after unsat routine) Unsatisfactory routine lab number: Chionne Residual Total Free 4 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: ISl I --- / Chlorinated:Yes No ❑Triggered(A1P) Chlorine Residual.Total Free__ ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) I l ❑E.con ❑Fecal Fitina Yes—_-No 5.®Samoa Coasted for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ®Satisfactory ❑E.coli present ❑E.coif absent Bacterial Density Results:Total Coliform _I100m1. Ecoli 1100m1. Fecal Coliform /100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container 0 DateiTimp Received ince Number (a/7/i3 /(pr3Q 2. 0607-9 Receipt Temp C'. Method Code: Sr1 9223S Date Reported to DOH tab Use Onff IAA Pi DOH Lab-Sander/ er/ 285— DAM Row 031.319 OWN,nen r}-ttp:no!0.Pa4 I na or mar a.bnt ae 6a 525612't<ocirtr 1r1 t) Ti.an6 oar pEMbn we mist*0 at.Eon us gokIntoWeip 2200683 Mason County WA 08/10/2023 03:56:08 PM NOTCE eRecorded #189665 RecFee: $203.50 Pages: 1 ROBERT FLATH Return to: Robert Flath 113E Terrace Dr Lya-Q' 3 ' QOg53 Belfair, WA 98528 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) I(We),the undersigned grantor(s).hereby place this notice on record that the following described real estate situated in Mason County,State of Washington;to wit: OR 3 21 34 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 3 2_ _] _- 4 - 3 1 -- _0__IL Q__1._10_ is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These restrictions and conditions arc based on location of property and/or Water Resource Inventory Area or WRIA. WRIA: 14 Maximum Annual Average Gallons Per Day: 950 Dated on this_7_day of ,,on . Signature of Grantor(s): k4e4 Printed name of Grantor(s): D.& r 0 Grantee: Public State of Washington County of Mason I,the undersigned,a Notary Public in and for the above named County land State,do hereby certify that on this _�,day of . .20 2s3 Ti LA F 1.41 personally appeared before me,who is known to be the signer of the above instrument,and acknowledged that he(ss)(t)ey)signed it. Given,under my hand and official seal the day and year last aba ' • , i414111NS-W°,6' St GREGORY A RL SSELL ( Notary 411, and for the State of Washington, Notary Public n.� II State of Washington Residing at.r!�E9.___$�t��iK/w+ Commission a 134076 My commission expires: h 2C My Comm.Expires Aug 14, 2025 ( f