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HomeMy WebLinkAboutWAT2023-00269 - WAT Application - 10/2/2023 4ppvOvedjPct7H WAT 2() — 00 Al p`I f02—Px.,14, 415 N.6th Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 111N11. 1, Belfair:360-275-4467,Ext.400 -`*;t Building,Planning,Environmental Health Community Health Elma:360-482-5269,Ext.400 iur� 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:Ghl'6 t ,h i L�.�( 16-41 -idit 4�L Oc-�o2 I O A " , Mailing Address: 2 1 L aL LOUfk_phone: gap•4-KI. e,j p 0 Parcel Number: 3z,bs -'-4 - gLldv2_ I OlTyy-ic, 1, . 4KO a Type of Water System Reason for Application • ❑ Public/Community Water System (2 or more Building permit tiC12GL 3 011611, connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL JSK Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ 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. Print Name of Water System Manager Phone 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 4/27,2021 WATER WELL REPORT :tea_ DEPARTMENT OF Notice of Intent No. WE53210 ECOLOGY Unique Ecology Well ID Tag No. BPF036 Type of Work: IVWE State of Washington O Construction Site Well Name(if more than one well): O Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ❑O Domestic ❑Industrial ❑Municipal Property Owner Name Chris Chamberlain ❑Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 307 E Capital Prairie Rd. Construction Type: Method: E New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other 0 Dug 0 Air- ❑Mud-Rotary Tax Parcel No. 32008-43-90021 Dimensions: Diameter of boring 6 in,to 142 R Was a variance approved for this well? ❑Yes ❑' No Depth of completed well 142 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ti I 0 6 in. 0 139 .025 in. 13 I ❑ 0 I 0 Location(see instructions on page 2): ©WWM or 0 EWM ❑ I ❑ in. _ _ m ❑ I ❑ DID SW /-r/of the SE /;Section 8 Township 20N Range 3W ❑ I ❑ in. _ _ is ❑ I ❑ DID O I 0 in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.231953 Longitude(Example:-120.12345) -123.086869 Perforations: 0 Yes ❑No Type of perforator used Air No.of perforations 96 Size of perforations 1/4 in.by 1-1/4 in. Driller's l,og/Construction or Decommission Procedure Perforated from 118 ft to 124 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: 0 Yes Si No 0 K-Packer Depth ft information Use additional sheets if necessary. Manufacturer's Name Material From To ! Type Model No. Diameter Slot size in.from ft.to ft. Brown silty loam 0 4 Diameter Slot size in.from ft.to ft. Brown silty sand and gravel 4 32 Brown sand and gravel with clay binder 32 47 Sand/Ft7ter pack ❑Yes ©No Size of pack material Brown medium sand,multicolored gravel,loose 47 61 Materials placed from ft.to ft. in. gravel,brown medium to coarse 61 Surface Seal: Cs7 Yes ❑No To what depth? 18 ft sand,loose 97 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes El No Multicolored gravel,brown coarse sand, 97 Type of water? Depth of strata loose,wet 116 Method of sealing strata off Multicolored gravel,brown coarse sand, 116 loose,water 126 Pump: Manufacturer's Name Type: Brown silty sand,gravel 126 142 H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 305 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 87 ft.below top of well casing Date 8/28/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ©No ❑Yes r> 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 135 ft for 1_hrs. - Date 8/28/23 Artesian flow gpm Temperature of water 50 °F Was a chemical analysis made? ❑Yes E]No Start Date 8/25/23 . Completed Date 8/25/23 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❑PE—Print NaTe Josh Koepp Drilling Company Arcadia Drilling Inc. Signature _� / /� Address PO Box 1790 6.... ---- License No. 2874 v �� / City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 8/25/23 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 877-833-6391. Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 qq yxov�aly 360-967-7010 V�» �Q3�✓l'- COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected CAM MASON 08/30/2023 > 1 d d PM Month Day Yea Type of Water System(cheat only one box) El Group A 0 Group B ®Other _-- Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: CHRIS CHAMBERLAIN Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 I Cell Phone:( ) Email: Eve.Phone:( ) Send results to:(Print full name,address and zlp code or e-mad) art eta@arcadiadrillirq.tem AND sue©arcadiadrillinp.00rn SAMPLE INFORMATION Sample collected by(name):SETH Specific location where sample collected: Special instructions or comments: #BPF036 307 E Capital Prairie Rd,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(A/P) 2.0 Repeat Sample(ANP) 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 I S I I f Chlorinated:Yes No_ ❑Triggered(A/P) Chlorine Residual:Total Free El Assessment (A/P) 4. Surface or WWI Raw Source Water Sample(Enumeration) S I I ❑E.coi ❑Fecal Firbred Yee_No ®Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and W Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform _1100m1. E.coli____. /100m1. Fecal Coliform___ 1100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container 0 Date me eceived: 0i23 two tab Reference i23CNumber f 35 Receipt Temp C': Method Code: SM9 2 -56 Date Reported to DON Lab Use Only DOH LabSampie# 285- ecn rams qit)19;efi. We7 y emareaevnrm n::tr. ry,rt.grww�O'27(iMT,cal frry 2202959oj�MASON CO WA 10/0312 1#1.n11111441 11 CHRIS E11W1111��>IIII�INILIRLAIN 41191406 DM e 111111111111!411�1 Pates 2 Return To C ;r'- ek A-ICJ 2 30 1 C Pn?It WPC. S *k3 CAllyNAP 61`6 01 Grantor(s): (1) A-kQ,1S C_\-k-wty KiiLL , (2) Grantee(s): (1) PUBLIC r Legal Description (1) IZ. 2 - Lc) /Z S� l t? I b 5P 4(-1(-1 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1W3 _ 0 0 - ' 6 - �( U 0 �- 1 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: 4 Maximum Annual Average Gallons Per Day: SL-\) gallons Dated on this L. day of C' me i._ , 202- . Signature of Grantor(s): (1) t/`v ?�/�,-.�( L:;r -� , (2) State of Washington ) County of Mason ) Page 1 of 2 I tt1111k I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this a` day of C..kuva - , 20 2:5 , C livik ktlee C Y om'o-tfb-tn 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. eLL )c3&u ; Qt) es oM CMG Notary Public in and for the State of Washington, oo �1AR,.-N S. residing at NA tf}501�1 (U1A. 1 V NoSAAy app•411 My commission expires: ()S-\S- 2; PUBIC ") 2 ( Page 2 of 2 Individual Water Well y • Water well report(attached to application). Depth I \ ft. Well capacity Test(attached to application) gpm w0 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. •476Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 1/15 16 22 Water use or limitation recorded N/A Yes>C Well Drilled Date (2�/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. l] 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: f Environ. Health: Date t ` (�Z� This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of2