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Home My WebLink AboutWAT2023-00310 - WAT Application - 9/25/2023 WAT aba9) - DO'S l a 415 N.61h Street 7 : 4\ MASON COUNTY Shelton,WA 98584 Agri ..r COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 am`:/ Belfair:360-2.75-4467,Ext.400 �"dti' Building,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400 Hl".' 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 1 Name on Applicant:C�u1��e � CAA-A,-4 i"�.entNl I ate: 9Y /Z G Mailing Address: 110 &Sur, �/t ei' �1/514' hone: s-30 -7()8 -///j i I Parcel Number: 2.2-J,27 7c-- Cki1So2, Type of Water System Reason for Application ❑ Public/Community Water System (2 or more A Building permit �71d 202.3 - O 130 I connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL I Well ❑ Boundary line adjustment ' M 1l tejtcle" 0 Spring/surface water Q, l 0 Other(explain) Other(explain) A-D 1A. ❑ 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' Q3Gar / Water Facility Inventory(WFI) Number: nonE (write"none"for two-party) )"( ' am the manager of this water system. The water system has been approved for ca> services. There are presently 0 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 - t by state and local regulation. Signature of Water System Manage a__ A A..d . - Date l0Jd,/23 ri— This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 4/4/2018 • Individual Water Well I `//��Water well report(attached to application). Depth `9 ft. ell capacity Test (attached to application) gpm 1 �� 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. \/JZ_2c23-- C�Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 K 15_16_22_ Water use or limitation recorded N/A Yes Well Drilled . . . Date t / [1 (L 2 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). Reviewer's Signatures: Environ. Health: 4) L-4 \ }I Date . �-7 ` Z;-. This form may be scanned and available for public view at www.co.mason.wa.us. I'a,,c'of 2 WATER WELL REPORT . DEPAR1MEN1 OF Notice of Intent No. WE47143 _ C-=L- d•! ECOLOGY Unique Ecology Well ID Tag No. BNX182 Type of Work: MOilit state of Washington O Construction Site\Veil Name Of more than one well): O Decommission r_=-s Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: E Domestic 0 Industrial 0 Municipal Property Owner Name Graciela Lopez 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 110 Passage View Rd, Construction Type: Method: 1E New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 Dug 2 Air- 0 Mud-Rotary Tax Parcel No. 22127-75-90152 Dimensions: Diameter of boring 6 in.,to 196 n- Was a variance approved for this well? D Yes [D No Depth of completed well 196 n. If yes,%%hat was the variance for? Construction Details: Wall j Casing Liner Diameter Front To Thickness Steel PVC Welded thread N IO 6 in 0 193 .025 in. B I ❑ EIO Location(see instructions on page 2): B WWM or❑E\VM O I 0 in. _ _ in. ❑ I 0 ❑ I 0 SE t/.-'h of the SE '/;Section 27 Township 21N Range 2W ❑ I ❑ in. _ _ in O 1 ❑ ❑ I ❑ ❑ I ❑ in. _ in- ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.276318 Longitude(Example:-120.12345) -122.909663 Perforations: 0 Yes C No Type of perforator used No.ofperforotions_ Size of perforations—in.by—in. Driller's Log/Construction or Decommission Procedure _ Perforated front—ft.to—ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and Screens: 0 Yes ❑No 2 K-Packer Depth 190 ft. nature of the material in each layer penetrated,with at least one entry for each change of 1/ information Usc additional sheets if necessary. �� n Manufacturer's Name Alloy Machine Works Material From To • Type Stainless Slotted Model No. Diameter 5" Slot size.018 in front 191 n.to 196 ft Brown silty sand and gravel 0 41 D Diameter Slot size in.front R.to ft. Gray silty sand and gravel 41 45 D Brown silty sand and gravel 45 54 - Sand/Filter park:❑Yes l7 No Size of pack material ru • Materials placed front n.to n. Gray silty sand and gravel 54 70 E Gray clay 70 81 DL Surface Seal: )Yes 0 No To what depth? 20 ft. Gray silt 81 110 Material used in seal Bentonite Chips 110 112 Brown silt Did any strata contain unusable ssater? 0 Yes t7 No O Type of water'7 Depth of strata Brown silty sand and pea gravel 112 115 Method of sealing strata off Gray silty clay 115 117 E Brown peat 117 122 Pump: Manufacturer's Name Type: Gray clay and gravel 122 127 - 1 LP. Pump intake depth: ft Designed flow rate:—gpm Gray silty sand and gravel 127 133 Water Levels: Land-surfice elevation above mean sea level 180 n. Gray medium sand,some gravel 133 149 a)• Stick-up of top of well easing 1 ft.above ground surface Black sharp gravel,fine gray sand,silt 149 168 - Static seater level 156 ft.below top of well casing Date 1/17/22 Gray silt 168 173 • Artesian pressure lbs.per square inch Date O Artesian water is controlled by (cap,valve,etc.) Black sharp gravel,medium gray sand,wet 173 182 Black gravel,medium black sand,loose,water 182 196 j Well Tests: 3 Was a pumping test performed'? s7 No 0 Yes r—' by whom? - Yield —epnt with_ft.drassdossn after hrs. D• Yield gpnt with_R.drasvdown after lies. RECEIVED Yield gpur with ft.drawdown after hrs. Lt Recovery data(time=zero when pump is turned of-water level measured front well • top to water level) APR 0 L' 2022 Time WaterLccel Time Water Level Time Water Level WA State Department u — — of Fc olo CSVIRO) _ Date of pumping test_ _ Railer test gpm with_ft.dtawdossn after_hrs ▪ Air test 20 gpm with stem set at 185 R.for 1 hrs. Date 1/17/22 L E Artesian nosy ppnt L Temperature of water 49 °F Was achemical analysis made? 0 Yes E No Start Date 1/14/22 Completed Date 1/17/22 IWELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well D construction standards.Materials used and the information reported above are true to my best knowledge and belief a, U Driller❑Trainee 0 PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature // Address PO Box 1790 License No. 2874 ` 77 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/17/22 ECY 050-1-20(Rev 09/18) If you creed this document in an aleinate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability cart call 877-833-6341. 2203785 MASON CO WA 10/26/2023 10:17 AM NOTCE GRACIELP LOPEZ 4192064 Rec Fee. $204.50 Pages: 2 1111111111113 HI 1111111118111111111 3111E111111111H PI Return To S - r2 o —g-Y Grantor(s): (1)F" (C CI ti`r Ler , (2) Grantee(s): (1) PUBLIC CC, rr 1 Legal Description (1) �� )'?.11 S1f`(,SUS✓� -Viz. LUG" B dr y� 1 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) a - 5,5 - 1 U I 5 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: +`T Maximum Annual Average Gallons Per Day: q gallons Dated on this day of QQ 6C4,' , 200,1J,. Signature of Grantor(s): (1G,/-LCiaL 4 , (2) State of Washington County of Mason ) Page 1 of 2 i mp z 190/1,1* 4_1 I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 154bday of ('7C-4-0 bcy , 20 ah , C'rYccEi r.tcc. 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. \\��tt • t u��/ `��Q�p ''„ss,o�••',i '% Notary Pul in and for the State of Washington, NO7 a� t'1 '.O= residing at � T tion m OBL- My commission expires: % ,c be,.• ' O � .,////"pS,HitNG'�\��. Page 2 of 2