HomeMy WebLinkAboutWAT2023-00315 - WAT Application - 11/3/2023 WAT ?-0-3 - 00315
."1 415 N.6th Street
/1 . MASON COUNTY Shelton,WA 98584
,Y •I I- 1 i COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
i -1 `./ Belfair:360-275-4467,Ext.400
\�z, -/ Building,Planning Environmental Health,Community Health Elma:360-482-5269,Ext.400
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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"T C 0v Date: ,(/3/?0a-�j
Mailing Address: 766 Nam{ /q1 fe- c'libi U Phone: 3L90 - (%7- 3 j
Parcel Number: 3-2/ -11-0g-0/O
Type of Water System Reason for Application❑ Public/Community Water System (2 or more \7 Building permit PjL1 } -O( --17
connections) ❑ Division of land:
TA Individual water source (one connection). #of Parcels? SPL
I* Well 0 Boundary line adjustment
0 Spring/surface water ❑ 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( F Number:
(write"none" for two-p y)
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.
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 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:\EH Forms\Drinking Water Revised 4/4/2018
-Tv 15, --, I \-ed cur In
A 2c_cc +i c,.. f l,n`) Individual Water Well
(Water well report(attached to application). Depth QD D ft.
' Well capacity Test (attached to application) \c gpm ? 8 O 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.
egl Satisfactory bacteriological test(attach to application).
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 r
Well Drilled .1.Vf Q®/..aa. s . . . . Date I01 ).,3/aQ a3
f
Individual Spring/Surface Water
❑ WDOE permit(attach to application) 6
❑ Method of disinfection
O 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.
i Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
R-1-7\9---VV\-C
Reviewer's Signatures: ( (1- 3
Environ. Health: �/' Date 2'1 "
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT Y.� DEPARTMENT OF
es = Notice of Intent No. WE54477
WILECOLOGY Unique Ecology Well ID Tag No. BPF060
Type of Work State of Washington
CI Construction Site Well Name(if more than one well):
❑ Decommission e> Original installation NOi No. Water Right Permit/Certificate No.
Proposed Use: El Domestic 0 Industrial 0 Municipal Property Owner Name Kent and Mertene Cobb
0 Dewatering 0 Irrigation 0 Test Well ❑Other Well Street Address 1041 E Sunset Hill Rd
Construction Type: Method: City Shelton County Mason
El Newewwell 0 Alteration 0 Driven 0 Jetted 0 Cable Tool
p Deepening 0 Other ❑Dug iii Air- ❑Mud-Roary Tax Parcel No. 221341102010
Dimensions: Diameter of boring 6 in.,to 200 ft. Was a variance approved for this well? ID Yes ❑' No
Depth of completed well 200 ft.
Construction Details:
Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread Q WWM or El EWM
p 1 0 6 in. 0 200 .025 in. 3I 0 El I 0 Location(see instructions on page 2):
❑ 1 ❑ b• in. ❑ I ❑ DID NE V.�/.of the NE V.;Section 34 Township 21 N Range 2W
❑ I ❑ in. _ in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.269474 N
❑ 1 ❑ in. _ in ❑ I ❑ ❑ 1 ❑ Longitude(Example:-120.12345) -122.913004 W .
Perforations: ❑Yes NI No Type of perforator used Driller's Log/Construction or Decommission Procedure
PNo.er of
fromm It to Size
below ground surface of edffro Sire of perforations—in.by__in. Formation:Describe by color,character,size of material and structure,and the kind and
Per — — nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes I]No 0 K-Packer Depth_ft. information. Use additional sheets if nerr«°ry.
Manufacturer's Name Material From To
Type Model No. groan gravely fine sand,tight,dry 0 16
Diameter— Slot size—m from __ft to—ft Diameter Slot sill in from ft to ft Brown fine sandy gravel and silt,tight,dry 16 34
— — — Brown gravelly medium sand,moist,tight 34 55
Sand/Fiter pack:0 Yes El No Size of pack material—in. Gray sift,moist tight 55 73
Materials Placed from 1i to It Gray
silty clay,stiff,dry 73 88
Surface Seal: p Yes 0 No To what depth? 19 ft Gray silt,wet 88 94
Material used in seal Bentonite chips Gray clay,stiff,dry 94 126
Type
• strata contain unusable water? ❑Des No Gray silty clay,wet,fine sand 126 145
o of water? Depth off strata 145 149
Gray clay,stiff,dry
Method of styling strata off Black fine sandy silt and gravel,wet,heaving 149 168
Pump: Manufacturer's Name Type: Black fine sandy gravel,water,silt bound 168 187
H.P.— Pump intake depth: 1i Designed flow rate: gpm Black coarse sand,pea gravel,active,water 187 200
Water Levels:Land-surface elevation above mean sea level 183 IL
Stick-up of top of well casing 1 ft.above ground surface
Static water level 181 ft.below top of well casing Date 10/17/23
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? M No 0 Yes C by whom?
Yield gpm with ft.drawdown after Ins.
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) Water Level
Time Water Level Time Water Level Time
Date of pumping test
Bailer test _gpm with _R drawdown after hrs. 10/17/23
Air test 15 gpm with stem set at 180 ft.for 1 bus. Date
Artesian flow__gem made? 0 Yes No Start Date 10/16/23 Completed Date 10/17/23
Temperature of water 51 °F Was a chemical analysis
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.
Drilling Company Arcadia Drilling Inc.
CI Driller 0 Trainee 0 PE—Print Name er ythian Address PO Box 1790
L afore City,State,Zip Shelton,WA 98584
License No.2053 Contractor's
IF TRAINEE:S or's License No. Date 10/17/23
Registration No.ARCADDI098K1
S rtsor's Si flue
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.
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
oee.are.aev,Ap 360-967-7010 \Ia31Qa.�'\
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COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tme Sample County
10/23/2023 co ed o a 041 MASON
_ems
Ate Day Yea
Type of Water System(check only one box)
❑Group A ❑Group B ®Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# -- -- --
Syst m Name KENT COBB
Contact Person:Arcadia Drilling,Inc
Day Phone:(360 )426-3395 Cell Phone:( )
Email: Eve.Phone:( )
Send results to:(Print UI name,address and zip code or e-mail)
arleta@arcadiadrilhng.corn AND ienn@ar.:adiadrilling.corn
SAMPLE INFORMATION
Sample collected by(name):SHAD
Specific location where sample collected: Special instructions or comments:
#BPF060 1041 E Sunset Hill Rd,Shelton
Type of Sample(select only one type of sample from types 1 through 5 below)
1.❑Routine Distribution Sample(NP) 2.❑ Repeat Sample(NP)
Chlorinated.Yes No (from distribution system after unsat routine)
Unsatisfactory routine lab number
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
[ SI l
Chlorinated:Yes No
❑Triggered(NP) Chlorine Residual:Total__Free_
❑Assessment (A/P)
4. Surface or GWI Raw Source Water Sample(Enumeration) I 1 J
❑E.cob ❑Fecal red Yes_No_
5.j Sample Collected tor information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Conform Present and ®Satisfactory
❑E.cob present ❑E.cof absent
Bacterial Density Results:Total Coliform /100m1. E.co6 /100m1.
Fecal Coliform 1100m1. HPC 11 ml.
Replacement Sample Required: ❑TNTC 0 Sample too old
aD Sample Volume 0 Damaged Container ❑
Dale:ime Recered. Lab Relere W1ar10er 1
10•w-N-a3 Dov.SNo.A V a.3 aL1-
Receipt Temp C: 4.b•O Idetbod Code, S M 92 2 3 B
Date Reported to DOH Lab Use Only.
DOH Lab-Saigle#
285-
00-Fare qJl 313 lekara Dar 7j.nsou wce+e alloaor ran ettearekrnak tat sa S250117(MUM ea 711)
Pre.4:eM r+Graser.we aretce al wow dcI,wf 7v,deaa psar
2203703 MASON CO WA
10/23/2023 03:08 P11 NOTCE
COBS it191994 Rec Fee: $204.50 Pages: 2
Return To '7 jr.\ �- MAY U , Cobs 111411111
105 Welvc- ( A-ve y-
4c 312
Grantor(s): (1) ke..+n'1 v hi, , (2) M tr l cv,c G. (glob
Grantee(s): (1) PUBLIC
Legal Description (1) Tad. OF NE
•�
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2, . 1 3 4 - l 1 - O 2 O I v
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: 14-
Maximum Annual Average Gallons Per Day: - L50 gallons
Dated on this 3 day of O1-f'J3 , 20 2 3.
Signature of Grant r(s)
�/
(1) , ����;� T , (2) ->,)
State of Washington
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 2 3 day of C -fP -1r , 20 27. ,
P,Vl+- avyt e(-limn e. personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he (she) (the is ned it.
GIVEN under my hand and official seal the day a� ear last abo - -
\\`0111iii+uiirrrr� Nota' c in a•. for the ate of Washington,
• STA N T ,�'�i
Q�;•.`8s►on •.O,i � -: .t 1`�` a Yt v v1
:F� ) m•'•
:• V° ��pTARY `' i = My commission expires: S—I D — 2 -7
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