HomeMy WebLinkAboutWAT2023-00318 - WAT Application - 11/7/2023 WAT ao a -- oO3 I
MASON COUNTY
COMMUNITY DEVELOPMENT
, Permit Assistance Center,Building,Planning
415 N 6th Street, Bldg 8, Shelton WA 98584, ���D
Shelton: (360)427-9670 ext 400 :Belfair: (360)275-4467 ext 400 • Elma: (360)4FR
FAX(360)427-7787
Application for Determination of Water Adequacy NOV — 1 2023
Instructions 615 W. Alder Street
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 µ iaecl
�/ vl,� ENTAL
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application. HEALTH
Part 1: Applicant! Parcel Identification
Name on Applicant: Ng01„ti„,„1 S L,,1't,c111 Date: \V-1/1.
Mailing Address: Lilo' M..A.„..,, aE„�L, 94 N'1 01.1_,-,,.Phone: (So';) 3 3 '- - 11,3
Parcel Number: �'Lt 0 5 510oo 1-L �� hEso,
Type of Water System Reason for ApplicationElPublic/Community Water System (2 or more l ' Building permit 77L.Q R icn 093— 01-55 1
connections) ❑ Division of land:
W Individual water source(one connection), #of Parcels? SPL
® 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
4 Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
,l Water Facility Inventory(WFI) Number:
(write"none"for two-party)
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.
El 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.
]:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
r Water well report (attached to application). Depth 2 /°' ft. 4
XWell capacity Test(attached to application) .1 0_ gpm ? (6(/ a 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.
ySatisfactory bacteriological test (attach to application). Z(7 0 7 70 u/
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 141-X1 151 1161 , 1221 j
Water use or limitation recorded N/A I I Yes itl AFV:not/24S
Well Drilled Date 7+ (O(G-13
Individual Spring/Surface Water
❑ WDOE permit (attach to application)
O 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)
y Satisfactory Determination:
This determination does not address adequacy of the distribution system, guarantee a . c3estuate supply of
water indefinitely in the future, or guarantee compliance with all applicable WDOE w resoiArcl regull,a,tiQ
Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68.b40-lietecr i,nation f �,
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chafe ,N�.
36.70A RCW. MAR
1 Unsatisfactory Determination: IT z�?4
Applicant's water supply does not appear adequate to meet the needs of its inte W ppollowing
" NV(ROPr;�;ENTAE HEALTH
reason(s). QUA
viewer's Signatures:
Environ. Health: iii) --- Date 3 (/ /Za 1,-
2 of
CSD Director: Date
DEC 2 1 2023
RECEIVED 7�s
' ° WELL REPORT _ DEPARTMENT OF NoticeoflntentNo. Wiz 'Za23— V"'° -(9
ECOLOGY Unique Ecology Well ID Tag No. try g12 ( 010
T�ay(pc of Work: "Will State of Washington
1Ci Construction Site Well Name(if more than one well):
❑ recommission Original installation NOI No. Water Right PrrmitfCertiteate No. -
Proposed Use: 15t Domestic ❑Industrial ❑Municipal Property Owner Name -s(E S ho G VY)akr
0 Dewatering ❑Irrigation ❑Test Well ❑Other j L ��. leg
Well Street Address 7 V • fqlVe It left
Construction Type: Method: ►�(piny County N10.5 M
New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool Cityty
0 Deepening ❑Other 0 Dug 0 Air- ❑Mud-Rotary Tax Parcel No. 3 2I OCC 10 0 O IL
Dimensions: Diameter of boring Y in.,to 2-43 ft
Was a variance approved for this well? Cl Yes o
Depth of completed well 2122 ft
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
M I ❑ _kl__in. O 21I7 ,25 in. I ❑ ❑ 1 ❑ Location(see instructions on page 2): 0 WWM or 0 EWM
❑ 1 ❑ in. _ in. ❑ I ❑ ❑ 1 ❑ �v W 1/4-1/4 of the hI W'/.;Section ? Township 2L Range W
❑ ❑ in. _ in. ❑ I ❑ O ❑o 1 ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) +f'0 21i 14•Q t t N
Longitude(Example:-120.12345) IV;G 05 t 2.1. I t W
Perforations:r❑Yes \A 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:‘ill,Yes O Npp ,XN.-Packer Depth 247. ft. information. Use additional sheets if necessary
Manufacturer's Name .1oh1n5M Material From To
4
Diameter Type * Zo ins size IC Model No. iictY.f p in 0 DiameterS in Slotusfrom3J ft.to� ft ZS
Diameter in. Slot size_ in from_ft to ti f^(t-ravel_Vet O)Va�r C I --- `a t
Sand/Fitter pack:0 Yes KNo Size of pack material in 9 Y A K I woo►s "/L ew h )r7 o
cis Materials placed from R to_1t 6l Ya VY ( 1 Q y sr r { O
�s� I►�A ,.,e 1 ( iv rev ►^) \ Th ` I LI
Surface Seal: 'Yes 0 No To what depth? L.0 ft (�4,Ws N c Ya V(� (y�L''�-) —1 4V I'f
Material used in seal BGt01^l S a_Y1el/el✓1d-V e 1 Eli Uw�'t 1 k.i; 1 2p
Did any strata contain unt}asaabbk,orate(.' ❑Yes �,No m�a��{ 20 l Z
'Type of water? D1'a'`b+r�' Depth of strata _J
Method of scaling strata off I.);COW r SO-V`.4 rat VC I 22O 2 To
�- a c_oot. SC-' 5 i r'- 114'01C-l/wc I ?- 2
Pump: Manufacturer's Name Type. I 17p Clea r GJ'a re l /Car-
H.P. I Pump intake depth:2 ft Designed flow rate:L_gpm l, rwx.c Ym �/ � aY,
Water Levels: Land-surface elevation above mean sea level k' ft. t
Stick-up of top of well casing '3 ft.above ground surface
Static water level Ill) ft below top of well casing Date I U/•"/L3
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc)
Well Tests: f I
Was a pumping test performed? 0 No l�,Yes by whom? .Aa✓�r1
Yield O gpm with I fi drawdown after I hrs. I7►'1\llrl
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 ,
3'oS g"ti 3:t0y 'nil ---
Dote of pumping test VI 41/25
Bailer test p gpm with 0 ft.drawdown after Z his.} l
Air test _gpm with stem set at_ft for_hrs Date
Artesian flow gpm � } I23
Temperature of water _°F Was a chemical analysis made? ❑Yes O No — Start Date_��/) 1 r D/2� IZ Completed Date
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
construction standards.Materialsused and the information reported above are true to my best knowledge and belief.
)(Driller❑Trainee❑Ply-Print Name Jack- ei nit rt!e Drillint Com li av 1a pg
Signature J Address 1353D fy t ()IJ ►7�C I FA i✓ �VY
License No. 2 59 City,State,Zip cijf I feet V W Ft '1 4Z. .
IF TRAINEE:Sponsor' License No. Contractor's r L
Sponsor's Signature Registration No. U.05' oZ0- 3L3 Date /
•
ECY O50-1-20(Rev 08/I9)Ifyou 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.
Nathanael Shoemaker
WA12023-00318BLD2023-01351
321055100012
231 E Arellem Rd
3/1/2024
Confirmed by Nathanael Shoemaker that both pictures were taken on 3/1/2024.
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Type of Water Syuern(check only arts boot) ,❑ A ❑ p g $OUisr��'Cl lY� 4...% /
Group A and Group B s—Pimidefun Vita Fea"ibes branixy(WFI� I. �/ F��2 /
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4,Surface or GWI Raw Sauna Water Sample(E a abort) 1 8 1 1 f
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Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C
...Where experience matters Poulsbo,WA 98370
Phone: (360)779-5141
www.spectra-lab.com L(A7
FEB 2202(
RECE/vED
Spectra Labs - Kitsap,LLC (Poulsbo) received samples for Grande Drilling on Tuesday,February 20,
2024 at 1:20 pm. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
236976-01 Nate Shoemaker Well Head 02/20/2024 7:30
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
Attachments
01)
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
02/22/2024 Page 1 of I
2204245 MASON CO WA
ENV1Rp r'n�ENTq 11/07/2023 SHOEMAKER
ER NOTCE
iñi
MAKER RecFee: 50 Pages: 2
L Illlllil illlllllllllllllllllllllllIIIIIIII IIIIIIIIIIIIIII III
•
HEALTH LO avR3—013 1
Return To
N,,kkGv, \ W inL RECEIVED
ip4Q RiAW i
011 ,,ek u� gi�Soz
NOV - 1 2023
615 W. Alder Street
•
Grantor(s): (1) N AWtrnvso,Q,1 , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) HIGHLAND PARK#1 LOT: 12
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 1 0 5 _ 51 0 0 0 1 2
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: 950 gallons
Dated on this i day of k)r)Ve_cr-t 'i', 20 Z..3
Signature of Grantor(s):
(1) , (2)
State of Washington
4 County of Mason
Page 1 of 2
I
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this -1 day of 11JU\16' .f , 20 ,
tiGa \ '1nc , kpersonally 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.
KELSEY TWIDWELL Notary Publre in and for the State of shington,
Notary Public
State of Washington residing at - 2 (A) ' c r SAC
License Number 22037379
My Commission Expires My commission expires: JCA OU(Art 1 c Z,(jZ—*/
January 20, 2027
Page 2 of 2
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