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HomeMy WebLinkAboutWAI2023-00304 - WAI Health Waiver - 10/15/2023 WAT 2b -c 30` I MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 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: JEFF MILES Date: 10-15-23,#� Phone: �7 awe_4t43eit- Mailing Address: L,L}1 5� I,J,I'S�v►ti. �a5ittelh `I► Parcel Number: 42135-50-00042 `-� �l'��� UJ A Type of Water System Reason for Application O Public/Community Water System (2 or more 0 Building permit VI LI ' i,d i-U I?+0� connections) 0 Division of land: O Individual water source (one connection), #of Parcels? SPL O Well ❑ Boundary line adjustment O Spring/surface water 0 Other (explain) O 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 10-15-23 This form may be scanned and available for public view at www.co.mason.wa.us. J:\Eli Forms\Drinking Water Res iced 125 2018 Individual Water Well `Fr Water well report (attached to application). Depth 175 ft. Well capacity Test (attached to application) 2---0 gpm 7 -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. Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planning 1451 151 1161 122n Water use or limitation recorded N/AL Yes Well Drilled Date 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: Q.V\/"\ Date (Z‘12 2 of CSD Director: Date , WATER WELL REPORT . `€J DEPARTMENT OF Notice of Intent No. WE53760 ECOLOGY Unique Ecology Well II)Tag No. 8PF047 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission Cr Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: III Domestic ❑Industrial 0 Municipal Property Owner Name Jeffrey Miles 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address Clear Lake Rd Construction Type: Method: O New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason 0 Deepening ❑Other 0 Dug 0 Air- ❑Mud-Rotary Tax Parcel No. 421355000042 Dimensions: Diameter of boring 8 in.,to 175 ft- Was a variance approved for this well? ❑Yes 0 No Depth of completed well 175 ft_ If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread l3 I ❑ 6 in. 0 171 , .025 is l3 I ❑ © 1 ❑ Location(see instructions on page 2): I3 WWM or❑EWM ❑ I ❑ is - in. ❑ I ❑ ❑ 1 ❑ NE /.-'/.of the SW 'V.;Section 35 Township 21N Range 4W ❑ I ❑ in. in. ❑ I ❑ ❑ 1 ❑ ❑ I ❑ in - - in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.263503 Longitude(Example:-120.12345) -123.162533 Perforatiom: 0 Yes Ijl 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 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 10 K-Packer =z) Depth 169 ft. information. Use additional sheets if necessary. 1 Manufacturer's Name Alloy Machine Works Material From To Type Stainless slotted Model No. Diameter 5' Slot size.018 in from 170 ft.to 175 ft. Brown silty sand and gravel 0 8 Diameter Slot size in.from ft.to ft. Multi-colored gravel and silt,loose 8 18 Brown silty sand and gravel 18 85 Sand/Filter pack:❑Yes El No Size of pack material_in. Materials placed from ft.to ft. Brown silty sand and gravel,tight 85 124 Multi-colored gravel,brown medium sand,loose 124 134 Surface Seal: E Yes ❑No To what depth? 18 ft. Multi-colored gravel,brown medium sand,water 134 175 Material used in seal Bentonite chips Did any strata contain unusable water? 0 Yes J No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: H.P._ Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 384 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 115 R below top of well casing Date 10/3/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No 0 Yes e) 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) Time Water Level Time Water Level Time Water level -Date of pumping test Bailer test_gpm with_ft drawdown after hrs. Air test 20 gpm with stem set at 160 ft.for 1-hrs Date 10/3/23 Artesian flow_gpm Temperature of water 49 ^F Was a chemical analysis made? 0 Yes ©No Start Date 10/3/23 Completed Date 10/3/23 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. O Driller❑Trainee❑PE-Print Name oeep Drilling Company Arcadia Drilling Inc. 17 Signature '/i� Addressity,StP, Box he90 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License o. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 10/3/23 ECY 050-1-20(Rev 09/18) If you need this document in an alternate format.please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. TOL Vanguard Laboratory • j v -I Zd2 2635 Parkmont Lane SW, Suite A Olympia WA 98502 Q�xoo�dD 360-967-7010 tO0 ..-15 I Vb COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 10/06/2023 0 4 5 illAM MASON RECEIVED OCT3 1 1 LOL3 1hnth Day Yes - PM Type of Water System(check only one box) OCT 26 2023 RECEIVED 0 Group A 0 Group B ©Other_PVT Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): 615 W. Alder Street ID# System Name: CRAIG GREGORY Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( ) Email: Eve Phone.( ) Send results to (Pnnt full name,address and zip code or a-ma') arieta@arcadgdrilling.com AND lenncarcadiadrlllino corn SAMPLE INFORMATION Sample collected by(name):MAX Specific location where sample collected Special instructions or comments. #BPF047 Clear Lake Road,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(A/P) 2.❑ Repeat Sample(AIP) Chlorinated:Yes No (from distribution system after unsal mutiny) Unsatisfactory routine lab number: Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: [ S I I I / Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total _Free_ ❑Assessment (AN) 4. Surface or GWI Raw Source Water Sample(Enumeration) S I 1 I ❑E.coil 0 Fecal Fdbred Yes No _ 5.0 Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and JI)v)Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results-Total Coliform_ /100m1. E.coli /100m1. Fecal Coliform /100m1 HPC /1 ml. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0_ Date/Time Received: Lab Reference Number 10/06/2023 17:00 AF V`a 3M,t Q.-`5 Receipt Temp C Method Code 8.8 SM9223B Date Reported to DOH n/a Lab Use Only DOH Lab-Samplerr 285— bole Fom eriTi9i . .cmir:.ryo.reed he;Weapon,,nesen.en lame•r/I aoosgsourlTobiTY as lilt TN,.rid oea p,Elofemn N enletb M ev+l drat Hgeoaveuyeel.r OCT 3 1 2023 RECEIVED 2203848 MASON CO WA Return To 10/27/2023 02:29 PM NOTCE MILES #192116 Rec Fee: $204 50 Pages: 2 k FE IIIIIIII III IIII III IIIIIII III IIIIIIIIIIIIIII!I!I I III IIII III III 04-7 -c IA/E 7 J S IE`�vc LAV Bc64- Grantor(s): (1)3 Z-1)n �T�' f t/ /' /P S , (2) Grantee(s): (1) PUBLIC Legal Description (1)0031A-V6 Pek. r1154A 2 31 di n,. 1iv i I ?tti' 41-i1 3'40 (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 'l 2 `? - :.5 C' - 0 0 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: I`1 Maximum Annual Average Gallons Per Day: `2(.) gallons Dated on this 1 day of 0 C+t, -- , 20 Signature of Grantor(s): (1) , (2) State-d W hin9 ton ) County of Mason I 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 q‘,01~' day of 0 ckobei , 209.75 , t,1 AV VA eS 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. Amoi 4, , Q't���s-2p'T4i'• .•o`' �� my Notary Public in and for the State of Washington, � AR�• N residing at \ 0Sbv1 CD UA. = •.m� o^=o My commission expires 2 1 Page 2 of 2