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HomeMy WebLinkAboutWAT2023-00311 - WAT Application - 10/25/2023 WAT 010212) - W 21I e 4^ 415 N.6th Street z MASON COUNTY Shelton,WA 98584 .11. sa 'o r'x COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 kil't Belfair:360-275-4467,Ext.400 Buildng,Planning,EnvironmentalHealth,CommunityHealth EIma: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: I�rck.C.t-k- cu Lree zi n Date: 1 b/ZS1Z3 Mailing Address: / 1(6 C Pcisrci Ut c w 1 L'Hone: 530 —7 i 8 /6 /y Parcel Number: �A /).7-- 75 -- 70 %5„Z s h44-°'1 I wft. sT<r = a Type of Water System Reason for Application ❑ Public/Community Water System (2 or more / Building permit 1j td aO2112,D1,0 A connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL 0 Well 0 Boundary line adjustment 0 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. 4 MA- p __ e _t Part 2: Water Connection Information ' 7.3,b0oS— ` Complete the section appropriate for the type of water connection being evaluated: ,-(�� Public Water System v" Name of Water System: 0 s CG\ V J Water Facility Inventory(WFI) Number: 11 (write"none"for two-party) fd I am the manager of this water system.The water system has been approved for_tservices. 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 nd local regulation. 7 Print Name of Water System Manag Phone 330 -766-j6/T Signature of Water System Manager .rn ,-P,1 cA Date f 0/2S1Z3 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Rcviscd 4/27/2021 . Individual Water Well Water well report(attached to application). Depth 19, `0. ft. e.Well capacity Test(attached to application) �Q gpm 7 �� upd. 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. Kr Satisfactory bacteriological test(attach to application). c Q \ .k Z—Zc7 3— 000 s— I 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 �/ / /- Well Drilled Date t l('i. (2--Z- 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: F-� " " " I Date I l (712_:S This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 emommirommormir WATER WELL REPORT __ . i DEPARIMEN1 OF Notice of Intent No. WE47143 ! ECOLOGY Unique Ecology Well ID Tag No. BNX182 Type of%York: State of Washington l 1 Construction Site Well Name(if more than one well): ❑ Decommission r---. Original installation NOI No. Water Right Pemtit/Certiftcate No. Proposed Use: ❑O Domestic ❑Industrial 0 Municipal Property Owner Name Graciela Lopez ❑Dewatering 0 Irrigation ❑Test Well 0 Other Well Street Address 110 Passage View Rd, Construction Type: Method: O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening 0 Other 0 thug ©Air- 0 Mud-Rotary Tax Parcel No. 22127-75-90152 Dimensions: Diameter of boring 6 in.,to 196 ti. \Vas a variance approved for this well? ❑Yes I7 No Depth of completed well 196 fl. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter Front To Thickness Steel PVC Welded Thread (E I 0 6 in. 0 193 .025 in. 0 I 0 E I 0 Location(see instructions on page 2). EA WWM or 0 EWM ❑ I 0 in. _ in ❑ I ❑ ❑ I ❑ SE Y.-%of the SE 'Vr;Section 27 Township 21N Range 2W ❑ I 0 in. _ _ in. ❑ I ❑ ❑ 1 ❑ ❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.276318 Longitude(Example:-120.12345) -122.909663 E. Perforations: ❑Yes C No Type of perforator used No.ofperforations_ Size ofprdoration s—in.by—in. Drillers Log/Construction or Decommission Procedure — Formation:Describe by color,character,size of material and structure,and the kind and _ Perforated front IL to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of 3 Screens: O Yes ❑No O K-Packer => Depth 190 rt. information. Use 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 161 n.to 196 ft. Brown silty sand and gravel 0 41 O Diameter_ Slot size in.front n to n. Gray silty sand and gravel 41 45 o Brown silty sand and gravel 45 54 Sand/Filter pack:0 Yes l]No Sire of pack material is o Materials placed front R.to n. Gray silty sand and gravel 54 70 Gray clay 70 81 o Surface Seal: 0 Yes ❑No To what depth? 20 ft. Gray silt 81 110 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes fallo Brown Silt 110 112 D Type of water? Depth of strata Brown silty sand and pea gravel 112 115 2 Method of sealing strata off Gray silly clay 115 117 o Brown peat 117 122 Pump: Manufacturer's Name T>vc: Gray clay and gravel 122 127 I I.P.— Pumpintake depth: ft. Designed flow rate:—gpm p Gray silty sand and gravel 127 133 • Water Levels: Land-surface elevation above mean sea level 180 n. Gray medium sand,some gravel 133 149 1.)• Stick-up of top of well casing 1 ft.above ground surface - Static water level 156 II.below top of well casing Date 1/17/22 Black sharp gravel,fine gray sand,sill 149 168 >' Gray silt 168 173 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Black sharp gravel,medium gray sand,wet 173 182 L L Black gravel,medium black sand,loose,water 182 196 ✓ Well Tests: ii Was a pumping test performed? O No 0 Yes c----:> by whom? — Yield gpnt with_ft.drawdown alter hrs. • Yield gpm with_ft.drawdown after lux. RECEIVED Yield ppm with A.drawdown alter—his. V t �/ L,J as tar Recovery data(time=zero when pump is turned off-water level measured from well • top to water level) APR 0 e 2022 Time Water Level Time Water Level Time Water Level 5 5 WA State D partmcryt u — — — of E'co!o9y v...WRO) _ Date ofpumping test_ _ fl nailer test gpm with_ .drawdown alter_hrs • Air test 20 gpnt with stem set at 185 ft.for 1 hrs. r Date 1/17/22 5 Artesian flow ppm — Temperature of seater 49 °F Was achcmicat analysis made? 0 Yes E7 No Start Date 1/14/22 Completed Date 1/17/22 R. WELL.CONSfRUCTION 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. ar r. — D Driller 0'IYainee 0 PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature �— "— /���,f Address PO Box 1790 License No. 2874 !/ r�/ City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor'shicensc No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/17/22 ECY 050-1-20(Rev 09/1 S) If you need this document in an alternate format,please call the Water Resources Program at 360-407.6872. Persons with hearing loss can call 711 for Washington Relay Service. Person with a speech disability can call 877.833-6341. 2203784 MASON CO WA 10/28/2023 10:17 AM NOTCE GRRCIELR LOPEZ *192064 Roc fee: $204 50 Pages 2 Return To I i i e. U 1-if e Z, d 17166 )i reweecJ 1-L Sh e Urik W � !8 S tj/ Grantor(s): (1) &rcIfIct I /k2 , (2) Grantee(s): (1) PUBLIC Legal Description (1)i 17-ppr 0r50/1/.&.14i�'1 1 oil) ( p*q-46t (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) c c) d 7 - (75 - ci U ( 5 Z 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: l4 Maximum Annual Average Gallons Per Day: d1 L) gallons Dated on this day of OektJrc✓ , 20 `x' Signature of Grantor(s): (1)C:::AALLAA )yyLe7— , (2) Washington State of Washin ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this )6 day of , 20A3 , G-ra c. ] If: LDz 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. ,j4/-64 ` G "' • C. ''% Nota Publi ! an for the State of Washington, P.• omission Notary .� g residing at Shc(--4vo • NOt4,9L, w'Z _ r- �•Mb My commission expires: I7f 2( co 0F��mbet 8"5.•,�Q\\��� i///////tIA 111.1k H+NG\�� Page 2 of 2