HomeMy WebLinkAboutWAT2023-00233 - WAT Application - 9/6/2023 WATT - trio104 I
MASON COUNTY
1,1F r COMMUNITY SERVICES
BuJding,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: }•arch- ` y ► Lert., UX, Date: 61-La• 00A 3
Mailing Address: 241BD 1,0€41.L ip_, )4VE Phone: a0(//• '1'?. g2a
Parcel Number: ,pIn.92o- '06A n -0: �h, �u 410wn
Type of Water System Reason for Application 1
Public/CommunitWar System (2 or more � Building permit-6 ld 20Z3 - 610,5 l
connections) Wj t.i 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other explain)
❑ Other(explain) ( p In)
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
t
Name of Water System: ! 1 ,(01C. A4 c t1 , .(,Yv..
be
Water Facility Inventory(WFI) Numr) nOinE 1
(write"none"for two-party)
12( I am the manager of thi water system.The water system has been appRroved for 2 services.
There are presently 1 connection(s)in use.This will be the d 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 prove} ater to this(these)connection(s)without exceeding
the limits of the water system or any lirtji et local regulation. / /
Signature of Water System Manager Date pr 6! 2 1
This form may be scanned and available for public view atWwyv.co,rnason.wa,us,
J:1E1l Forms lDrinking Water Revised Il25R0it
il
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) qpm 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 htto;//ois.co.mason.wa.us/planninq 141 151___1 160220
Water use or limitation recorded N/Al Yes,
Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
O Method of disinfection
O 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
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Part 3: Mason County Community Services Evaluation (staff use only)
O 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:
Applicants 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
CSD Director: Date 2or2
WATER WELL REPORT " DEPARrMEN1 Of Notice of Intent No. WE49142
ECOLOGY
Types Work: State of Washington Unique Ecology Well ID Tag No. BNV853
p Construction Site Well Name(if more than one well).
❑ Decoavnisssion c— Original imWlatioo NOI No Water Right Pemnt/Certificate No
Proposed Use: E Domestic 0 Industrial 0 Municipal Property OWnet Namc Catherine Maior
0 Dewataring 0 lrrigwioo 0 Test Well 0 Other
Well Street Address 620 E South Island Drive
Coaatruetioa Types Method:
O New well 0 Alteration 0 Driven 0 Jetted D Cable Tool City Shelton County Mason _
D Deepening ❑Other ❑Dug 1 Air- D Mud-Raiary Tax Parcel No. 22010-30-91002 -.w_-�-
Dloeesioes: Diameter ofbeeing a t a,to 115 R.
Depot of compacted well 115 R. Was a variance approved for this well? ElYes allo
Ca.aoractlaa Detain Wad If yes,what was the variance for?—___-- -
Casing Liner Diameter From To Thickens Sind PVC Welded Thread
51 I 0 6 in. 0 110 .025 in (3 I ❑ E7 I 0 t.ocalion(see instructions on page 2). L4 WWM our❑EWM
❑ I 0 in in ❑ 1 0 DID SW V ys of the NW tb;Section 10 Township 20N Range 2W
DID in _ in ❑ 1 ❑ ❑ 1 ❑
❑ I 0 in. in O ( ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.235003 N
Longitude(Example -120 12345) -122.9246211 W
Perforations: 0 Yes O No Type of perforator used
No ofperforaiom Size of perforation to by_rat Driller's Loq/Csostruetioa or Decommission Procedure
Perforated from_R.to_R below grtsuhd six ee Fomtation:Describe by color,ehaeacse,size of material and structure,and the kind and
suture of the materiel in each layer penetrated,with at least one entry for each thane of
Scat teas: O Yen 0 No lil K-Packer L.4' Depth 109 R. information Use aditionel sheets if necessary.
Maoufacnrer's Name Alloy Machine Works ,------- Material From To
Type Wire Wrapped Model No.
Diameters Slot size.014 in from 110 g,to 115 1 Brown gravely fine sand,tight,dry 0 9
Diameter Slot sire in.6om R.to R. Brown line sandy gravel,silt bound,tight,dry 9 33
Brown San4/Pl r pads:0 Yes NI No Size of pack automat_in fine to medium sandy gravel,tight welps 33 es
Materials)heed Crow ft to ftBlack fine silty sand,heaving 68 74
Black fine to medium sandy gravel,tlgtl,wet 74 76
Surface Seal: G7 Yes 0 No To what depth? 20 R. Gray clay,stiff,dry 76 98
Material treed in seal Bentonite Chips
Black Did any strata contain unusable water? 0 Ye El No gravelly medium sand,heaving,water 98 115
Type of water? Depth of strata_ ._ Black clay like silt,soft 116 115
Method of sealing strata off
Pomp: Manufacturer's Name Type'
H.P. Pump intake depth:_R Designed flow rate _gpm '
-Water Levels Lard-surface elevation above mash sea level 56 R
Stick-up of top of well casing 1_4 ft.above pound surface
Static water level 51 ft.below top of well casing Date 9/8/22 __
Artesian presatae lbs.per square lath Date
Artesian water is controlled by (cap,valve,etc.) i
Well Ten:
Was apimtping test performed? O No 0 Yes by whemt
Yield um with_it.drawdoeeu after_M.
Yield gpm with ft.drawdown alter hrs.
Yield _gpm with ft.drawdown alter_hrs.
Recovery data(time°^zero when pomp is turned off-water keel measured from well
lay to water level)
Time Walter level Time Water Level Time Water Level — --
Date of pursytng tat
Haler test gpm with—�R drawdown alter his
Air test 20 gpm with stem set at 100 ft for 1 hrs. Dane 9d8122
Artesian flow gpnr
Temperature await' 51 •F Was a chemical snaly,is made? ❑Yes II No Stan Date 9/8/22 Completed Date 9/8/22
WELL CONSTRUCTION CERTIFICATION: I constructed andlor accept responsthility 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
El Driller 0 Trainee❑PE— ' me Rogeray Phythian Drilling Camper»Arcadia Drilling Inc.
Signature Address PO Box 1790
License No. 2053 Cit.),State,Zip Steelton,WA 98584
IF TRAINEE?Sponsor's Lic o Contractor's
Sponsor's Signature - Registration No.ARCADD1098K1 Date 9/8/22
t--t,ear f C-
r'i i i `e a b f ECY U50-1-20(Rev 09f I S) Ilya('need this rfocumeu in an alternate formal,please call the Warty Resources Program of 360-407-6871.
printestiffeff with bearing loss can crap 71I for Washington Relay Service. Persons with a speech disability can call 877.133-6341.
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1786 SR Mile Hill Drive
_bap Port Orchard,WA 98365
J SPECTRA
www4pectra-blb.COM
(360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Deb Sample Cobden 11rne Semple Count/
edema
9 / 20 / 22 ClAid Mason
3 60
164 0.
'fps of Villa Spites(rasa only we bair)
DA 0 Grow 8 ID011ier
Group A awl Group II Syetens-Preside tom Wrier Faces Inventory(WRY
DO
*leo flow Forest Majeure,LLC
Carted Permit Arleta EledefArcedla Mang
Del PhrieL 346424-33e6 Cd Ftione:
- - —
Emit netraiseareadaddling.oarn E .Row
Surd meas fibt Maim Mem rd*code Cr•4110
erietadtereadadriling.coen
Arcade Delllirigt,Inc
- - —-
SAMPLE INFONMATION
sample collected by(a MAX
Spedlc location Mem sande collected Saida let or comments:
SIMMS COUNTS PLEASE
520 E South bind Drive,Shelton
TM of Suede(deck only one boll)
I.D Raabe Detrholon Swede 2.Raped Semple(atir urea.roulne)
Chlorinate&Yes 0 No 0 0 Dleatufai System
Chlorine Resided Tod_Foe__ Uneeneleclory routbe Lib number.
3.Source Ground Vans Rub Sample
ISI I I Unsatisfactory routine laded
CalorinMet YOB El No
0 TrImyeed
0
aloft Residua:Tad_Free
Asemernent
4. &unmake flowt*Wiler Ike* I 8 1 1 I
E COI [(Fecal-swum.eht.IF1131-Flood Yu Ns D
5. Sentpl•C.Obetbd br trameslon Ordr.
LAB USE ONLY DRWIONG WATER RESULTS LABpSE ONLY
0 Unsadebolory Tata Cant Present anti
E.colireseot Ecoll absent
Replacement fin*Required
DS.rbodihcn) 0 MC 1- 0
Baobab Deady Results:Told Collotfl4nigilf100mi. Ecat_<1.thisrPOOrol.
Fecal Caw _ /100m1. WC _ ml.
_ —
Lab tb member , F- liner=
I 3 Lq 01
**ad Cade: Da NOW Imetelet
_ SM B223 B 2.1 /93—
wamulai SEP 2 2 lin SEP 1 2 2022
iXNLrnq ty .(2
225 . 'I )45 3 0 wallow
rainswirre
Printed From Mai
Printed from Mason County DM,
ail • 01M
2202213 MASON CO WA
09/15/2023 01.45 PM NOTCE
FOREST MAJEURE LLC #190852 Rec Fee $204.50 Pages 2
III III III II VII 1110I IIIII II 011 IIIII 1101 III III I I I I I I IIII
Return To
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Grantor(s): (1) CCP/AY) v 4lr(2)
Grantee(s): (1) PUBLIC
Legal Description (1) Ir1E .L4 t )kT Ti.tv2O ►�i-2.
(Abbreviated form:i.e. lot block,plat or section, township, range)
Assessor's Tax Parcel: (1) oZ off, 0 1 0 -\ 0 - 9 I Q U a
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the undersigned grantor(s), hereby place this notice on record that the described real
estate situated in Mason County, State of Washington is subject to water use restrictions and
conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: I
14
Maximum Annual Average Gallons Per Day: n gallons
Dated on this day of , 20 213.
Signature of G o ).
(1) , (2)
State of Washington
County of Mason
Page 1 of 2
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I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this day of , 20 413 ,
VIttutica._ S�.snr, CI\o.c� personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and year last above written.
ANY BRUSS 4otary P lic'nand for the State of Washington,
:o NOTARy �N: / r sidin at k .(6, Ca 5$t{
209271 ommission expires: O7
- LP PUBLIC :o=?
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