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HomeMy WebLinkAboutWAT2023-00168 - WAT Application - 8/30/2023 ii, -.. - maw --w AUG 2 2 2f123 WAT 020212 - oo/CP 8 MASON COUNTY 415oN.WA6th Street �< � �% Shelton, 98584 i I j COMMUNITYShelton:360-427-9670,Ext.400 SERVICES 44 =1 =/ �(�yay Belfair.360-275-4467,Ext.400 \,,,, , ti� Building,Planning Environmental Health.Community Health u` ,4? Elmo Nit D RECE/�FO Application for Determination of a - ii equacy AUG 2 8 2023 Instructions 615 W. Alder Street 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/ Pa cel Identification • Name on Applicant: C-i 4. �r� t t S _Date: c3//6 2 3 Mailing Address: pi/v h t c- G‘,--- L.3 A Phone: S%C.) 6 G.� — 0 41 '( Parcel Number: Lf Z / 3 s'-- -SL7 - ()Do z.5- Type of Water System Reason for Application 0 Public/Community Water System (2 or more N. Building permit - Id 2023 -CO 6012 connections) 0 Division of land: Ill Individual water source (one connection), #of Parcels? SPL 175l Well ❑ Boundary line adjustment 0 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. 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) ❑ 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:\EH Forms\Drinking Water Revised 4i27i202 I Individual Water Well Water well report(attached to application). Depth f `1 ft. 0 Well capacity Test(attached to application) Z C) gpm 0 0 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/planninq 14 15_16 22 Water use or limitation recorded N/A Yes Well Drilled Date C' Individual Spring/Surface Water i I ❑ 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. 3 ; 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. Li 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 WATER WELL REPORT ,Akrzie DEPARTMENT Or Notice of Intent No. WE52163 ECOLOGY Unique Ecology Well ID Tag No. BPF071 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission ..—' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: 0 Domestic 0 Industrial 0 Municipal 0 Dewatering 0 Irrigation 0 Test Well ❑Other Property Owner Name Rick Phillips Construction T Welt Street Address Clear Lake Rd >pe: Method: lt]New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other 0 Dug l7 Air- 0 Mud-Rotary Parcel arcel No. 42135-50-00025 Dimensions: Diameter of boring 6 in,.to 140 ft. Depth of completed went 140 ft. Was a variance approved for this well? ❑Yes El No If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread N I ❑ 6 in. 0 136 .025 in. O 10 O 10 ❑ 1 0 in Location(see instructions on page 2). 3 WWM or❑EWM— in. ❑ 1 ❑ 0 I 0 NW '/,_y.ofthe SW Y.;Section 35 Township 21N Range 4W O I 0 in. in. ❑ 1 0 0 I 0 ❑ I 0 in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.262433 N Perforations: ❑yes ®No T Longitude(Example:-120.12345) -123.159824 W ype of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations in.by in. Formation:Describe by color•character,size of material and stmcituc,and the kind and Perforated fran ft.to ft.below ground surface Screens: Yes 0 Nonature of the material in each layer penetrated,with at least one entry for each change of O I:-Packer —' Depth 134 ft, information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works i' Wire Wrapped Model No. Material From To Diameter 5" Slot size.016 in.from 135 ft.to 140 ft. Fine to medium sandy gravel,silt,tight,dry 0 26 Diameter Slot size in.Coin ff.to ft. Brown gravelly fine sand,loose,dry 26 32 Sand/Filter pack:❑Yes El No Size of pack material in Black gravelly fine gray sand,gray silt bound,dry 32 44 Materials placed from R.to ft. Brown fine sandy gravel,silt bound,tight,dry 44 92 Surface Seal: a Yes 0 No To what depth? 19 ft. Multicolored medium sand,gravel,sharp, 92 Material used in seal Bentonite Chips tight,dry 113 Did any strata contain unusable water? 0 Yes El No Multicolored medium to coarse sandy gravel, 1�3 Type of water? Depth of strata water 140 Method of sealing strata off Pump: Manufacturer's Name Type: II.P. Pump intake depth: ff. Designed flow rate: gpm Water Levels: land-surface elevation above mean sea level 348 ft Stick-up of top of well casing 1.2 ft.above ground surface Static water level 105 ft.below top of well casing Date 8/4/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap•valve,etc) Well Tests: Was a pumping test performed? E No 0 Yes c , by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(tine-=zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Les el Date of pumping test Bailer test gpm with_ff drawdown after hrs.1 Air test 20 gpm with stein set at 120 ft.for 1 hrs Date 8/4/23 Artesian flow gpmI Temperature of water_°F Was a chemical analysis made? 0 Yes E1\o Start Date 8/4/23 Completed Date 8/4/23 \TELL CONSTRUCTION CERTIFICATION: !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 arc true to my best knowledge and belief. Driller LJ Trainee❑PE—Print N R er Phythian Drilling Company Arcadia Drilling Inc. Si nature - 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 8/4/23 EC 050-1-20(Rev 09/I S) If you need tins document in cut alternate format,please call the If iuer Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Itirshington Relay Service. Persons with a speech disability can call 877-833-6341. Vanguard Laboratory 2635 Parkmont Line SW;Suite A • Olympia WA 98502 aLalwesr 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 08/15/2023 C o'iz led on„ MASON Mena, Day Yes rM Type of Water System(check only one box) ❑Group A 0 Group B I*Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI) fCz System Name: RICK PHILLIPS l Contact Person:Arcadia Drilling.Inc Day Phone:(360 )426-3395 Cell Phone.( ) Email: Eve.Phone:( Send results b:(Print lull name.address and zip code or a-marl) ar:eta Q arcaniatlnlIcg ccm AND sue©arcadiadnling ccm SAMPLE INFORMATION Sample collected by(name):Seth Specific location where sample collected: ) Special instructions or comments: ai3PF071 Lot#9 Clear Lake Rd.Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A/P) Chlorinated Yes _ No worn o.slnouocn system after snout.routine) Chlorine Residual:Total_-_Free Unsabsfactkxy routine lab number: 3.Ground Water Rule Source Sample — — —Unsatisfactory routine collect date: s I I i Lhlorinated.Yes No ❑Triggered(A/P) -. Chlorine Residual:Total Free_-_ ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) Si I l ❑E.cob ❑Fecal F.:ered Yes No 5 IN Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and SSatisfactory ❑E.coli present ❑E.coG absent Bacterial Density Results:Total Coliform /100m1. Ecot- Fecal Colrform /100ml. HPC /1 ml Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ Rec 1 �- Las f Number �7. tip L 3 Crh () a tr—'10t Recetpt Te p Method Code- . 5'Ntg22313 �t%1�t}iNC I►w�1!' Date Reported to DOH Lab Use Only DON Lab-Sample \ L-' 3 0 • 285- !de.'rw Da!:,.M,a"M7 M a:4-rm so,..G T�rr-v al••r, • 2201485 MASON CO WA OB/30/2023 09:27 AM NOTCE PHILLIPS #190313 Rec Fee: $204.50 Pages: 2 Re rn To �IlMil�Mu I�I�������I III I�III �11011011 �I�I I �I II �II�I I� III rtit ( Hps !V L 4' 2 C,N Ca S L 5 BUJ AUG 3 12023 RE6EIVEp Grantor(s): (1) L C�.I�,��( �`Lr + (1 rr7f , (2) Grantee(s): (1) PUBLIC Legal Description (1) Yai �t,�.', 3 y 2/ J (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 2 I '3 rj - ' fj _ 0j O 0 Z 5 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: Maximum Annual Average Gallons Per Day: Dated on this ( 8 day of CO-I t �.,�,� , 20 Z 3. Signatur of antor ): J (1) lI , (2) State of Washington ) County of-Mterstr-r Cl'rk ) 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 1 (3 day of Au)V5-k" , 20 Zs , R�c hctrA Pi,.Ili p5 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 above written. n1QA • • Notary Public n and for the State of Washington, ELIZABETH DOSTAL Notary Public residing at U m P�j c. rrt n State of Washington [� Commission 7#22033964 My commission expires: 00 C. I y ?ZaZb My Comm.Expires Dec 14, 2026 Page 2 of 2