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Home My WebLink AboutWAT2023-00225 - WAT Application - 8/11/2023 WAT 247211) - 00 a 9,�? MASON COUNTY ^ I COMMUNITY SERVICES „Air Building,Planning,Environmental Health,Community Health ,C,:.H�L�s 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: Ke,1- /1 2 /Sow / Date: /;/ 3 Mailing Address: 70 ^�c W�^y S ;W 4 Phone: 7-3-3- 3 7 p- ? Parcel Number: 2'24 7-g - 77- Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ftfBuilding permit -Kid :).69,91' U Di Ci LP connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL C Well 0 Boundary line adjustment ❑ Spring/surface water 0 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: (write"none"for two-party) 0 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 www.co.maso�n'/wa.us. J:\EH Forms\Drinking Water Milimillimmiimilloommilw Individual Water Well Water well report(attached to application). Depth /5:1 ft. Well capacity Test (attached to application) ?� gpm 7- 500 9pd. ll 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. Ep Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 151 (16n 22n Water use or limitation recorded N/A 0 Yes Ii Well Drilled . . Date 7/3O/7 0/� • Individual Spring/Surface Water O 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. 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: a p / Environ. Health: CIIVII R Date ` I`�1-? -5 012 CSD Director: Date • -57. WATER WELL REPORT CURRENT PCL Ectrot Original&1"copy—Ecology,2°a copy—owner,3'a copy—driller Notice of Intent No. WE31576 ErrorConstructlonf aorntitisMe rV'ynn circle) Unique Ecology Well ID Tag No.BKR144 . [Si C li13: Readlmage Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATION Property Owner Name Robert Ferrier Position: Ari e of Intent Number PROPOSED USE: ® Domestic ❑ Industrial ❑ Municipal Well Street Address 110 Vineyard Dr 0 Dcwaur 0 Irrigation 0 Test Well 0 Other City Shelton County Mason TYPE OF WORK: Owner's number of well(if more than one) Location SE 1/4-1/4 SE 1/4 Sec 28 Twn 21 N It 2W FWM 0 ® New well ❑ Reconditioned Method:❑ Dug ❑ Bored 0 Driven or ❑ Deepened ❑ Cable ® Rotary 0 Jetted (s,t,r Still REQUIRED) vvwat DIMENSIONS: Diameter of well 6 inches,drilled156 ft. Depth of completed well 166ft. CONSTRUCTION DETAILS Lat/Long Lat Dog 47 Lat Min/Scc 16'20"N Casing ® Welded 6" Diam,from +1.5 R.to 156 R I,on . h Deg 122 Long-- Min/Sec 55'54"W Installed: 0 Liner installed " Diam.from ft.to ft. Tax Parcel No.(Required) 221287790012 D Threaded " Diam.From ft.to ft. Perforations: 0 Yes ® No CONSTRUCTION Olt DECOMMISSION PROCEDURE Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and in.and no.of _from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change SIZE of perfs_in.by perfsof information. (USE ADDITIONAL SHEETS IF NECESSARY.) Screens: ❑ Yes 10 No 0 K-Pac Location MATERIAL FROM TO Manufacturer's Name Brown silty sand,gravel, 0 Type Model No. loose 12 Diam. Slot size from ft.to ft. Brown medium sand,some 12 Diam. Slot size from ft.to ft. gravel,loose 51 Gravel/Filterpacked: 0 Yes 0 No Size of gravel/sand Brown medium gravel with 51 Materials placed from ft.to ft. silty clay binder 57 Surface Seul: ® Yes 0 No To what depth719ft. Brown silty sand,gravel 57 75 Material used in seal Bentonite Chips Brown fine silty sand,gravel 75 Did any strata contain unusable water? 0 Yes ® No wet 95 Type of water? Depth of strata Gray fine to medium sand, 95 gravel 97 _ Method of sealing strata off 97 120 Gray clay,stiff PUMP: Manufacturer's Name Black medium to coarse sand, 120 Type H.P. _- gravel,wet 135 WATER LEVELS: Land-surface elevation above mean sea level 176 ft. Black coarse sand,gravel, 135 Static level 106ft.below top of well Date 7/30/2018 water 152 Artesian pressure lbs.per square inch Date Brown coarse sand,gravel, 152 Artesian water is controlled by (cap,valve,etc.) water 156 WELL TESTS: Dawdown is amount water level is lowered below static level Was a pump test made? 0 Yes ® No If yes,by whom? Yield: gal./min.with_ft.drawdown after hrs. Yield: gal./min.with_ft.drawdown after las. Yield: gal./min.with ft.drawdown after hrs. Realm),data(lime taken as zero wren pump turned off)(water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of test Bailer test gal./min.with_ft.drawdown after Jlus. Airtest 20 gal./min.with stem set at 140n.fur 11us. Artesian flow___g.p.m. Date Start Date 7/30/2018 Completed Date 7/30/2018 Temperature of water 49 Was a chemical analysis made? D Yes ® No WELL CONSTRUCTION CERTIFICATION: 1 constntcted and/or accept responsibility for construction of this well,and its compliance with all Washington well constntction standards. Materials used and the information reported above are true to my best knowledge and belief. ®Driller❑Engineer 0 Trainee Name(punt Josh Kocpp Drilling Company Arcadia Drilling Inc. Driller/Engineer/Trainee Signature C/ v_, � St AddressPo Box 1790 Driller or trainee License No.2874 City,State,Zip Shelton Wa, 98584 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. ARCADDIQ28KI Date 7/3Q/2018 _ ECY 050-1-20(Rev 02/10) If you need this document in an alternate format,please call the IValer Resources Program al 360-407-6872. Persons with hearing loss can call 711 for IVashington Relay Service. Persons with a speech disability can call 877-833-6341. •I Vanguard Laboratory V 2635 Parkmont Lane SW,Suite A Olympia WA 98502 ytxavetaa 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected _ Time Sample County Collected ° -A — z3 :vv �o'u i\r1 As ot� Month Day Year Type of Water System(check only one box) ❑Group A ❑Group B 11Other Group A and Group B Systems-Provide from Water alities Inventory(WFI): ID# ti System Name: S /10 e:--V. y r� Contact Person: S // '��jr, " /V4(jcjil ..—Day Phone:( �b Y fO 'Y 'Cefl Phone:( )54 -( —Email: re, 4124 ural ,e:( ) - Serb results to:(Pent full name,address and zip code ore-mail) a /i 70 ��.•w�/ 470.7 SAMPLE INFORMATION Sample collected by(name):` p Specific Lion where sa lered:' Special instructions or comments: cl.-1 I S./art d f;/le A re' a 1( r4i's vP,frvpc''/7 c ^j Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(NP) 2.0 Repeat Sample(AIR) Chlorinated:Yes No (from distribution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample i I Unsatisfactory routine collect date: ISI I I I Chlorinated:Yes No ❑Triggered(AP) Chlorine Residual:Total Free ❑Assessment (A/P) — 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑�E.cok ❑Fecal Furred Yes_No 5.M Sample Collected br Information Only: ^LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifonm Present and ,Satisfactory ❑E.colipresent 0 E.coiabsent Bacterial Density Results:Total Coliform_ I100m1. E.coll _/100m1. Fecal Colifonn 1100m1. HPC /1 ml. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0_ Q DaleIrxne o I 5'r3Jec�^ t 3D mber la t u t L9-(J Receipt TeQ :f� Code: ku g223$ Date Reported to DOH lab Use Only. r6t t DOH lab-Sample# k 0 285 • - DOH Four F31-319(e7lxe a W 11.a you nevi ass gLYosem n an atir+pre bTen oee 800 5250127(TDMTY d III) Ilsa macaw Nakao*ma waiW a.w doh re ga..tlrrarq.abr 2201118 MASON CO WA 08/22/2023 02:27 PM NOTCE NELSON 11190020 Roc Fee. 3204.50 Pa es: 2 I IIIIIII 1II III Ilil1III III IIII IIII IIIII I1 III lit i IHa III IIII Return To O n l^Juy $ fay Grantor(s): (1) Ktrl / '11?'\ , (2) u %04 Grantee(s): (1) PUBLIC T2S /-3 01 cr * /Y7-° 4F V30945- PPS 0/ SE sr- Legal Description (1) bec /'f' -1 c A' 7../yo )/7 S 2/iL S y/93 (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) Z Z 1 . - 7 7- 0 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: 5-b gallons Dated on this 7- day of Ayr./rfi , 20 �• Signature antor(s): (1) , (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a N to Public 'n and for he above flawed County and State, do hereby c ify that on this j 'day of , 202--.2 , personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (�' - 1 igned it. GIVEN under my hand and official seal the day and year last above written. C ANNETTE H MCNEIL No Public in and or th tate of shington, Notary Public State of Washington residing atL I Co Number 198039 ire My commission expires: o 1 _ G-a' /_ My Commission Expires it March 15, 2026 Page 2 of 2