HomeMy WebLinkAboutWAT2023-00200 - WAT Application - 6/1/2023 RECEIVED
1. .
JUN - 1 2023 WAT-2oa3 (Dd-Rbo
615 W. Alder Street
415 N.6"'Street
MASON COUNTY EN VI Ro N EN T Shelton,WA 98584
• COMMUNITY DEVELOPMENT HEALTH A Shelton:36w27-9670,Ext.400
$elfair:360-275-4467,Ext.400
v�r„rcAuisbncec it Bursa Ptaninng Erna: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! Parcel Identification
Name on Applicant M.i-kwc t Lo-t t.1 Date: S-S"- 2 3
Mailing Address: b s-1 S E A-c c►s-o,A MO Phone: 34, a - 2 f.x -c,c 4,9
Parcel Number. 32 o�Vicki,v ?
Type of Water System Reason for Application
11 ❑ Public/Community Water System (2 or more lEF Building permit,,C,O 2LD 3 -CC631 5'D
connections) ❑ Division of land:
J Individual water source(one connection),id
#of Parcels?r SPL
Well 0 Boundary line adjustment
Springlsurface water 0 Othe (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.
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.
Signature of Water System Manager Date
This form may be scanned and available for public view at Mlww.Cojnason.wa.us.
J:1EH Forms\Drinking Water Revised 4/4rz0 1 s
Individual Water Well
Water well report(attached to application). Depth ] ft
Fr Well capacity Test(attached to application) !iJ gpm 7 U 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 welt 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)(
Wel Drilled Date <<410 12 Z
Individual Spring/Surface Water
L 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
• •
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.
Recomended approval indicates requirements of Sanitary Code,Title 6,Cuter 6.68. of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
J Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its Intended use for the folowing
reason(s).
Reviewer's Signatures:
En iron. He W) Date Ct(1 J 1 3
This form may be scanned and available for public view at www.co.mason.wa,pa.
Page 2 of 2
WATER WELL REPORT DEPARTMENT CY,. Notice of Intent No.WE51290
r 1 ECOLOGY Unique Ecology Well ID Tag No.BPS-126
Type of Work: "-=_-I State of Washington
tg Construction Site Well Name(if more than one well): --
❑ Decommission - Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: EI Domestic 0 Industrial 0 Municipal Property Owner Name Eric Russell
U Dz+catering 0 Irrigation rl Test Well 0 Other
— -. __ Well Street Address 5051 SE Arcadia Rd _
Construction Type: Method:
El New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason
U Deepening 0 Other ❑Dug t t Air- 0 Mud•Rotary Tax Parcel No.32025-50-00009
Dimensions: Diameter of boring 6 in,to 186 ft. Was a variance approved for this well? 0 Yes 0 No
Depth of completed well 184 ft.
If yes,what was the variance for?
Construction Derails: Wall
Casing Liner Diameter Front To Thickness Steel PVC Welded Thread
® I ❑ 6 in. +1.2 178 in. ® I ❑ ❑ I 0 Location(see instructions on page 2): ®WWM or❑IiWM
fl ICl in. i'I ❑ I ❑ ❑ I SE '/.-'/.of the NE '/A,Section 25 Township 20N Range 3W
0 I ❑ in. in 0 I ❑ ❑ 1 ❑
C.1 I U in. _ _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345)47.19265
Longitude(Example:-120.12345)-122.99187
• Perforations: Cl Yes C$No Type of perforator used
No.of perforations. _ Size of perforations__--in.by in. L)rillcr s Log/Construction or Decommission Procedure
S Z. Perforated from ft.to ft below ground surface Formation:Describe by color,character,size of material and structure,and the kind and
al nature of the material in each layer penetrated,withal least one entry for each change of
Screens: M Yes 0 No b9 K-Packer b Depth 176.7 ft information Use additional sheets if necessary.
a Manufacturer's Name_ _ -. - Material From To
Type Model No
1A Brown boulders cobbles gravel sand silt 0 3
Diameter 6Tele Slot size 18 in from 178.7 fl to 184 ft
Diameter _ Slot size in.front ft.to ft. Gray gravel sand silty clay 13 21
S Lt brown gravel silty sand 21 28
Sand/Filter pack:Cl Yes ®No Size of pack material in. Gray cobbles gravel sand silt 28 36
0 Materials placed from Il.to_ft.
— Gray clay 36 72
g Surface Seal: E Yes ❑No To what detath?18 ft. Grayish brown clay 72 79
65 Material used in seal BENTONITE CHIPS Grayclay
79 119
^ Did any strata contain unusable water? 0 Yes El No
Type of ssatei? Depth of strata • Gray gravel sand clay 119 137
Gray clay sand—saturated 137 143
Methodof sealing strata off Gray gravel sand clay—saturated 143 150
5 Pump: Manufacturer's Name Type: Gray clay 150 168
H.P.— Pump intake depth: ft. Designed flow rate: gym Gray gravel sand silt—water 168 184
o Water Levels: Land-surface elevation above mean sea level fl Gray silly sand 184 186
y Stick•up of top of well casing+1 ft.above ground surface
Static water level 124 ft.below top of well casing Irate 11/30/2022
Artesian pressure lbs.per square inch Date
7. Artesian water is controlled by (cap,valve,etc.)
3
Well Tests:
i i Was a pumping test performed? ff4 No 0 Yes ==> by whom??
Yield gpm with ft.drawdown after Ills.
—
] Yield gpm wmh_IL drawdown after hrs.
Yield gpm with ft.drawdown after. . ...hrs.
ei Recovery data(time=zero when pump is turned off—water level measured front well p.�
D top to water level) ALL 127.i\V IS....D --
Time Water Level Time Water Level Time Water Level
0 -- — —5 Q I:C 11 7 [it?i
U Date of pumping test .VA vtate Uepartmens
Bailer test gpm with_ft.drawdown after_hrs. of rr..f11oSy (SW RC).)
Air test 30 gpm with stem set at 181 ft.for 1.hrs. Date 11/30/20n .
v Artesian flow gpm
TemL. perature of water °F Was a chemical analysis made? El Yes No _Start Date 11/29/2022 Completed Date 11/30/2022
atWELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
] constnlction standards.Materials used and the information reported above arc true to toy best knowledge and belief.
y
U4 Driller U Trainee 11 PE,,—Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING - .
Signature ��-"Pi" 6'--1,,f Address PO BOX 44427
License No.2432 City,State,Zip TACOMA,WA 98448
IF TRAINEE:Sponsor's License No. -_ Contractor's
Sponsor's Signature Registration No.RICHAW'3210B Date 12/01/2022
ECY 050-1-20(Rev 09/18) If you creed this document in arm alternate format,please call the Water Resources Program at 360-407-6872,
Persons with bearing loss can call 711 for Washington Relay Service, Persons with a speech disability can call877-833.6341.
. a l "WATER l b 1.49gOd3-
111 MANAGEMENT od8d
ANIL LABORATORIES frrc:.MIMI
1515 Both St E,Tacoma,WA 95404
COLIFORM BACTERIA-ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
5 ' ! u3 1 : 3.,q f�����, RECEIVED
Mora a Day Year
Type of Water System(check only one box)❑Group A ❑Group B ❑Other=-_ 'f r JU N — 1 1 2023
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): 615 W. Alder Street
Sysiem Name: k . pi ts-5e
Contact Person:
2.41"sr7tI rr 3':7 02�i; NVIRONn ENTAL
Day Phone( ) Cell Phone:( ) f i�
Email:v Y<to(per{( �t� (�ggq}Eve.Phone:( ) HEALTH
seng. dox ii442 r
- :: Oma, KA -- —— -- 9644:>
•SAMPEE INFORMATION
Sample collected by(name):
r l-f-f), -- _
Specific location where sample collected Special instructions or comments:
.5-(.51 er 4-&c.). ' rat
Type of Sample(select only one type from types 1 through 5 below)
1.❑Routine Distribution Sample(A/P) 2.❑ Repeal Sample(AlP)
Chlonnated:Yes No nrom di51nbuUon s s:em ate..urisat rcu;nci
Unsatisfactory routine lab n,,mber:
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
ISi' --
j 1 i
Chlorinated:Yes _No___ .
❑Tnggered(A/PI Chlorine Residual:Total, Free
I ❑Assessment (AIP)
�4 Surface or GWI Raw Source Water Sample(Enumeration) I S I I I
❑E.oak ❑Fecal rure; 'cs vo
5.0 Samµe Cotle:ied for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and [ Satisfactory
0 E.co/present 0 E.coli absent I
Bacterial Density Results:Total Coliform_ 1100ml. E.coli lOOmi.
Fecal Coliform 1100m1. HPC /1 ml
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume ❑Damaged Container 0
iateffirne Received,_^L eC Lab Reference Number
Recerpt Temp C°: Method l A /7i22
0
DateRepaAed H ad Lab Use Only: "k.1:,.;R
3
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„� 05/12/2023 02:05 PM NOTCE
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Return To OL[29,,CR5-Oo8�O
(,AAA o I&L. RECEIVED
LQ 11 Ncc.cvt.. L)
k.,„..J A 955 SI 6 JUN - 1 2023
615 W. Alder Strc;;1
ENVIRONMENTAL
HEALTH
Grantor(s): (1) L_n tr\ }Y.0+..1.. 1 A L , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) 7-'2_ CA Oi cQ.C, 1\A'iX Cr2.t.k. ?•• L 1 t�t,i NE.t ZCio-3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) j- ( aZ 5 - 6 0 - G 0 V c) 1
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
1 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
I 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.
4
WRIA:
Maximum Annual Average Gallons Per Day: c1%U gallons
Dated on this day of KJkc.N , 202S -
Signature of Grantor(s): L
4
(1) , (2)
State of Washington )
ICounty of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
rtify that on this I '" day of n'1 , 20 Z3 ,
rrt personally appeared before me, who is known to be
signer of the above instrument, and acknowledged th t he) (they) ned it.
GIVEN under my hand and official seal the day and year last abo %'een.
Notary Publi anfor
/ fo r the State of Washington,
/
residing at ��+/" T e
My commission expires: Or -fig ZI
NOTARY PU8Lle
STATE OF WASHINGTON
JOMCE M SEVANS
Wf COMMISSION MIRES
MARCH IL
27
CCOMMISSION♦♦4364
I
I
I
Page 2 of 2
EXHIBIT"A"
THE SOUTH HALF OF THE SOUTH HALF OF THE SOUTH HALF OF THE SOUTHEAST QUARTER
OF THE NORTHEAST QUARTER,AND ALL THAT PORTION OF THE SOUTH HALF OF THE SOUTH
HALF OF THE SOUTH HALF OF THE SOUTHWEST QUARTER OF THE NORTHEAST QUARTER
WHICH LIES EAST OF MILL CREEK ALL IN SECTION 25,TOWNSHIP 20 NORTH, RANGE 3 WEST,
W.M., IN MASON COUNTY,WASHINGTON.
(SAID LAND BEING ALSO KNOWN AND DESCRIBED AS TRACT 9 OF THE UNRECORDED PLAT OF
MILL CREEK PARK)
EXCEPTING THEREFROM THAT PORTION CONVEYED TO MASON COUNTY UNDER AUDITOR'S
FILE NO.258230.
ALSO EXCEPTING THEREFROM RIGHT-OF-WAY FOR ARCADIA ROAD,COUNTY ROAD NO 91100.
2085315 Page 3 of 3 12/08/2017 03:57:59 PM Mason County,WA