The URL can be used to link to this page

Home My WebLink AboutWAT2023-00226 - WAT Application - 8/17/2023 WAT a,j9-3 -Obo1,�(p 415 N.6e'Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building.Planning Environmental Health,Community Health Elma: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: DAVID & KARYLIN SHOEMAKER Date: 8/17/2023 Mailing Address: 8393 E ST RT 3 SHELTON WA 98584 Phone: 541-499-4325 Parcel Number: 22129-24-50010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 121 Building permit $1,1)20.3-Ol O01 connections) 0 Division of land: 1Y Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water 0 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J\Eli Forms'.Drinking Water Revised 4/4/2018 • Individual Water Well 1d/ Water well report (attached to application). Depth 177 ft. `Z Well capacity Test (attached to application) 20 gpm ?-3°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. i/ Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14 16_22_ Water use or limitation recorded N/A Yes Well Drilled ............................................................... Date `L It(e 17, 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). ��,Ree�viewer's Signatures: Environ. Health: C ' I Date I I .% /23 This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 , WATER WELL REPORT I DEPARTMENT OF Notice of Intent No. WE49905 ECOLOGY Unique Ecology Well ID Tag No. BNV805 Type of Work: State of Washington t. Construction Sitc Well Name(if more than one Hell): ❑ Decommission r--> Original installation NO1 No. Water Right Permit/Certificate No. Proposed lase: nil Domestic 0 industrial 0 Municipal Property Owner Name David Shoemaker 0 Dewatering (7 Irrigation ❑Test Well 0 Other____ 1Vcll Street Address 8393 E State Route 3 Construction Type: Method: p New well 0 Alteration ❑Driven ❑Jetted ❑Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug fill Air- fT Mud-Rotary Tax Parcel No. 22129-24-50010 Dimensions: Diameter of boring 6 in,to 177 rt. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 177 ft. Construction Details: Wall if yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I ❑ 6 in. 0 177 .025 in. C4 I 0 O I 0 Location(see instructions on page 2): E WWM or 0 EWM ❑ 1 ❑ in. in. ❑ i ❑ ❑ 1 ❑ SE V.-1/4 of the NW %;Section 29 Township 21N Range 2W ❑ 1 ❑ in. _ _ in. ❑ l ❑ DID ❑ 1 ❑ in _ in. f7 I o ❑ 1 ❑ Latitude(Example:47.12345) 47.281017 Longitude(Example:-120.12345) -122.985979 Perforations: 0 Yes 0 No Type of perforator used r No.of perforations Size of perforations in by in Driller's Log/Construction or Decommission Procedure Perforated front ft.to R.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry foe each change of Screens: 0 Yes fit No ❑K.-Packer Depth_ft. information Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size_in.from _ft.to_8. Brown silty sand and gravel 0 13 Diameter_ Slot size___in front ft.to ft. Brown medium to coarse sand,gravel,loose 13 33 Brown silty sand and gravel,moist 33 47 Sand/Filter pack:U Yes LC No Sine of pack material in. Materials placed from ft.to ft. Broom medium sand,some gravel 47 103 Surface Seal: ®Yes 0 No To what depth? 19 ft. Brown medium sand,pea gravel,wet 103 127 Material used in seal Bentonite Chips Brown fine to medium sand,silt,water 127 136 Did any strata contain unusable water? 0 Yes ID No Brown silt,wet 136 152 Type of water? Depth of strata Black sharp gravel 152 156 Method of sealing strata off - Gray sticky clay,some gravel 156 170 Mulitcolored gravel,medium gray sand,water 170 177 Pump: Manufacturer's Name Type: H.P.— Pump intake depth: ft. Designed floss'rate: gpm Water Levels: Land-surface elevation above mean sea level 240 ft. Stick-up of top of well casing 1 ft.above ground surface Static watec level_ 96 ft.below top of well casing Data 2/16/23 --- Artesian pressure lbs.per square inch Date ------- Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? Sl No 0 Yes r: 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(time-zero when pump is turned off..water level neaswcd Suns well �� 4i � top to water level) Time Water I eve Time Water level Time Wales Level - APR 2 8 2n23 -------- Daofe pumping test WA State Dwpattiner t Bailer test gpm with_ft dntwdown after_lots. � Aix test 20 gpm with stem set at 160 ft.for 1 hrs. " Date 2/16/23___- of Ecology (SWI.10). Artesian flow gpm 'lemperatureofwater 49 °F Was a chemical analysis made? ❑Yes ID No Start Date 2/16/23 Completed Date 2/16123 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. Driller 0 Trainee 0 PE—Print Nat e Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 --t— /%� City,State,Zip Shelton,WA 98584 iF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI09BK1 Date 2/16/23 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360.107-6872. Persons with hearing loss can call 711 for Washington Relay Service, Persons with a.speech disability can call 877-833.63,11. [6276 Twelve rees Ln NWSte.0 !I--"' ,,SPECTRA Laboratories-KitsapPoulsbo,WA "-'-' ' ,Weer*exPerie,ce reamer* 370 96360)779-S141COLIFORM BACTERIA ANALYSIS FORM 9- Date Sample Collected Time Sample County /Qi 23 Collected i Abl /fi n I Da Yes _:_O PM Type of Water System(check only one box) �`' ❑Group A El Group B er-�[LIGC�7‹ Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# $,-e tile(et'e- SystemName: er3r5,Sre,re f/Lc/r 3 Contact Person: AG,ti ficif2 re Day Phony Cell Phone:Jae ce`C`S`t2. Emal:3a4:14 Sitp4,14 q_aiotie.Phone: Send meSondem:As trpielieener,flared efpcodeet mil Own forwaroniccopyanwke) ISAMPLE INFORMATION Sample collected by(name): i. ea re Specific loco ionlnere sample lected: Special instructions or comments: Weif`Jc°ac4 Type of Sample(check only one box) _ 1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(A/P) Chlorinated:Yes ❑ No❑ (from disDibuhon system after unsal.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample —— Unsatisfactory routine collect date: s / / Chlorinated:Yes No ❑Triggered (A/P) Chlorine Residual:Total Free_ ❑Assessment(A/P) 4.Surface or OWI Raw Source Water Sample(Enumeration) I S I I ❑ E.call ❑Fecal Filtered Yee No 5 Rank Curetted for Information only: ji USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑UnsatIsfectory Total Coliform Present and fairy ❑E.co/i present 0 E.cof absent / Bacterial Density Results:Total Conform mpn/100ml.E.coli mpn/100m1. Fecal Coliforrn .._ _cfu/100m1. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container 0 Lab Reference Number cirr /D ZY 130/0(—ol Receipt Temp C': Method Code. 9223B! T-COUNTI SM92220 Ape 71 77rnpa16errs eats tea a. the pens amuereb Ayy e D e� ' /y�y idstemed.Arty we,apyine a dibiaire Out then by he WiiWOyiecq 6urthatzed.ere lure Moine elm rgMr w .WLY arm phew Mei M WOK*mods*M 36-779.141 Ind DOH Lab-Sargk0 _ dwaoreurepm r�N ��1/ mw Whafrddw ahrbI ems.Wedend twoup6(y II OHO• YY 0 i! J in Ao;idweb*pea woe weer Acme by*Oa DON Fail e031-319(dbaer da17) 2201100 Mason County WA 08/22/2023 12:52:23 PM NOTCE eRecorded #190006 RecFee: $203.50 Pages: 1 SHOEMAKER Return to: DAVID &KARYLIN SHOEMAKER 8393 E STATE ROUTE 3 SHELTON WA 98584 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) 1 (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 2W 21N 29 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 2 2 1 2 9 __ 2 4 __ 5 0 0 1 0 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 WRIIA. WR1A: 14 Maximum Annual Average Gallons Per Day: 950 '1 Dated on this 4h /'1 day of L1 f{LA✓4. ,20 Signature of Grantor(s): J/�l l�+�w / - c :yG �\leCk-JLc 1 Printed name of Grantor(s): u), I �1 Ce 0,1 ,,1 t t�irr 1"r t2(€C Grantee: Public State of Washington County of Mason I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this 8 day of (Lu Op St ,20 2.3 , David Shtlemalcer Karts l i h ShoemaILWpersonally appeared before me,who is known to be the 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. ��111111111t1!/�� (72_ . t I-1 W 'S{IO If qJ`//i E' Notary Public in and the State of Washington, Z6-20 vc'o �NOTAgy~^aN = Residing at_�iJ 11 M Y1 Cl. 101.6111111 = My commission expires: 6 .aS'.' L 3;9).'4 umb ��•' 'c0?�: „6? tWAs \ I I