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Home My WebLink AboutWAT2023-00291 - WAT Application - 10/16/2023 > WAT 2z023 - C ci MASON COUNTY 1 44 , ! COMMUNITY SERVICES \ Building.Planning,Environmental Health,Community Health Fires 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 Identificationr Name on Applicant:JuiC / 4 Je Date: /l�(1 /e R()iZ 3 Mailing Address:97 /0/L54A) �!) &t�L� P�o / Y n : 3 rGg g/" /327 Parcel Number: --2 I Zs —?(� q eo z/4,' �/ Type of Water System Reason for Application _ ❑ Public/Community Water System (2 or more Building permit bo 2023 connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL `Well ❑ Boundary line adjustment D 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) 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. ❑ 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:\EII Forms\Drinking Water Revised 1/25.'201 R 3 Individual Water Well Water well report(attached to application). Depth 13' ft. L4' Well capacity Test(attached to application) gpm 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 r ort cannot be located by the applicant or if the water well report does not have a capacity test, a w I capacity test, which provides stabilization of draw-down and recovery data, must be performed b a licensed contractor. Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 1,WI 151-1 16(-12211 Water use or limitation recorded N/A WA Yes L 1 Well Drilled Date `CS-2 I —.2 j Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection El 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). ; YR� ieeviewer's Signatures: Environ. Health: (5 " l Date 1 l (« I'-/ 3 °` CSD Director: Date ouh WATER WELL REPORT r...jaria DEPARTMENT OF Notice of Intent No. WE53213 ECOLOGY Unique Ecology Well ID Tag No. BPF031 Type of Work: W State of Washington • Construction Site Well Name(if more than one well): ❑ Decommission --> Original installation NOI No Water Right Permit/Certificate No _ Proposed Use: i7 Domestic ❑Industrial ❑Municipal Property Owner Name Julie Meyer ❑Dewatering ❑Irrigation ❑Test Well 0 Other Well Street Address 30 E Lexington Place Construction Type: Method: ! New well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug GI Air- 0 Mud-Rotary Tax Parcel No 42125-76-90044 Dimensions: Diameter of boring 6 in.,to 138 ft. n Was a variance approved for this well? O Yes �No Depth of completed wet 138 fr. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread Q : D 6 in 0 138 .025 in. O I 0 l J , 0 Location(see instructions on page 2) Q WWM or 0 EWM O 0 in. in. ❑ I O 010 SW A-V.of the NE '/.;Section 25 Township 21N Range 4W O 0 in. _ in. ❑ 1 ❑ O ' O O ' ❑ in. _ _�in. ❑ 1 ❑ 010 Latitude(Example:47.12345) 47.283769 Longitude(Example:-I20 12345) -123.132212 Perforations: 0 Yes E No Type of perforator used No.of perforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Perforated from ft to ft below ground surface face 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 for each change of Screens: E Yes ❑No R K-Packet Depth 136 ft, information. Use additional sheets if necessary. Manufacturer's Name Johnson Screen Material From To Type Sand point screen __ Model No.. --- Diameter 2 Slot size.010 in.from 136 ft.to 139 ft. Brown silty sand and gravel,loose - 0 8 Diameter Slot size in.from ft.to R. Brown silty sand and gravel,tight 8 26 Sand/Filter pack ❑Yes No Size of pack material n Brown mediume sand and gravel with silt binder 26 97 Materials placed from ft.to ft Brown silty sand and gravel wet 97 101 Surface Seal: Yes ❑No To what depth? 18 R. I Brown medium sand,gravel tight,dry 101 110 Material used in seal Bentonite Chips gown medium sand,gravel,water 110 128 Did any strata contain unusable watery ❑Yes E No Multicolored gravel,coarse,brown sand,water I 128 I_ 138 Type of water? Depth of strata 7 Method of sealing strata off I I Pump: Manufacturer's Name Type 1l H.P.-- Pump intake depth'_ft. Designed flow rate gpm Water Levels: Land-surface elevation above mean sea level 324 ft Stick-up of top of well casing 2 ft above ground surface I Static water level 96 ft.below top of well casing Date 8/11/23 IArtesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No ❑Yes r=5 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 measured from well top to water level) 4 Time Water Level Timc Water Level Time Water Level Date of pumping test I Bailer test —gpm with_ft.drawdown after_hrs Air test 30 gpm with stem set at 120 ft.for 1 hrs - Date 8/11/23 Artesian flow gpm _ Temperature of water 49 °F Was a chemical analysis made? 0 Ycs E No Start Date 8/11/23 Completed Date 8/11/23 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. E Driller 0 Trainee 0 PE—Print N e sh Koepp Drilling Company Arcadia Drilling Inc. Sirntature Address PO Box 1790 License No 2874 ,� City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 8/11/23 ECY 050-1-20(Rev 09/18) II you need this document in an alternate format.please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 7/I for Washington Relay Service. Persons with a speech disability can call 877-833-6341. rt_I( /111— MANAGEMEN"T _ LABC)RAl-C)RIFS INC.— - _ 1915 80th St E. Tacoma,IVA 98404 4111 .1111milimil.7 Nor' COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 4gf ! n 1 J "n Collected•Mom Day year f—. `AIL'(]q,l I /11•J r _f I Type of Water System(check only one box) ❑Group A 0 Group B er _ Group A and Group B Systems-Provide from Water duties Inventory(WFI): System Name: ` � Contact Person: A.t=,_:ad1.3 Drilling, Inc Day Phone:( 360) 426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results to:(Print full name.address and zip code) Arcadia Drillin., Inc PO Box 1790 5helt_in, WA C8584-• i.—_ SAMPLE INFORMATION Sample collected by(name): 5r S.-cite location where sample collected: I Special instructions or comments: __..: •a 'n eL-44c 4 rn Type of Sample se:cf only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(A/P) 2.0 Repeat Sample(A/P) Chlorinated:Yes No from distribution system after unsat routine) Chlorine Residual.Total__Free _ I Unsatisfactory routine lab number: 3.Ground Water Rule Source Sample — — Unsatisfactory routine collect date: S -- --/--- --/—-- - Chlorinated Yes _ No_ _ 0 Triggered(A/P) Chlorine Residual:Total___Free .__ ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) GI E.soli ❑Fecal S F:tew Yes _ 5. ra' - pie Collected for Information Only:at — —— •: USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and 1 Latisfactory ❑E.coli present 0 E.coli absent 1 ' Bacterial Density Results:Total Coliform /100m1. E.coli _/100mi. Fecal Coliform /100m1. HPC /1 ml. +tie-placement Sample Required: 0 TNTC 0 Sample too old I 0 Sample Volume 0 Damaged Container 0 t in Recei i�(./1 11 Lab Reference Number Rece pt Temp C°: ° l is L�� Method Code: • Date sled to DOH ,n/ Lab Use Only: (1 d/jR l3 G/Jrl/f/f DOH Lab Samples 089 .L7 ] ( (P . -719( 00107)•nyoAvis)ea owkabnn an arwna.m M.ut WI WO 525 Cttr.TOCAIY cal MI TMir4Ma[+AM.ebi aril v.ka.:4ate byte ga:f'.,u.v..a. 2203415 MASON CO WA 10/16/2023 02.05 PM NOTCE Return To 110111111111IiIIII111I ll111111111II 11111I11I1IIIIiIIIII1111IIl9es. 2 t / ` 67-K t7 Wltsa > tam ?,cN--,V • Grantoe(s): (1) VfL1IE' l LU4_" , (2) Grantee(s): (1) PUBLIC �'"� y/ Legal Description (1) LDS ) D c 694 2.1 s { Pin DP liE fW 4 (1uN nE 5 I & (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 11 o'Z I a 5 _ 7 to _ o b 4 4 1-2 I -- 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 W A. WRIA: l`f Maximum Annual Average Gallons Per Day: WO gallons Dated on this /(0 day of b.-rt.)6&f , 20 z5. Signa of G ntor(s): S of Washington County of Mason Page 1 of 2 , • v` I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this k C. day of ()-?Cebef , 20'2,3 , 0 u\ 0— Make-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. . .---.aktt 4 nw 21 " . Notary P is in and for the State f Washington, Xs pia PASTeiti . `er 22O37376 residing at cW (,j (ekkr Sc My o,mmission Expires Jan, ary 20,2027 My commission expires: (tUC Ccl 7A t L0C'7 Page 2 of 2