HomeMy WebLinkAboutWAT2024-00063 - WAT Application - 2/1/2024 WAT - ODOW¢
MASON COUNTY
COMMUNITY DEVELOPMENT
rerm¢nssisurce cenov,rWldln&rlanNM
415 N 6n Sheet, BWg 8,Shelton WA 98584.
Shelton' (360)427-9670 ext 400 0 Belfair'. (360)2754467 ext 400 4 Elms: (360)482-5269 ern 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/f(P��arcel Identification �1
Name on Applicant: t-r4Y0y\ WYSC Datgpt a-i - 24
Mailing Address: IA''S WE \�A� sV U!ta+l V*hotie`yh 9iido 509 'V-19
Parcel Number: t 72_P- q 5 it,g 1 ..
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit _jO Z(,Q-I--I_0601
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
,8( Well 'Pz<X.AA- war- lb13- ❑ Boundary line adjustment
[ISpring/surface water V b l l ❑ 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/Communify 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)
❑ 1 am the manager of this water system.The water system has been approved for services.
There are presently connections) in use. This will be the connection.
❑ 1 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.
I.EH Forma\Dr Ring Wdter Rr isa1125Q018
Individual Water Well
Water well report(attached to application). Depth // 6 c) ft.�R� 00
Well capacity Test(attached to application) / vv opm�gpd.
The well driller often performs well capacity teats 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 hnp://gis.w.mason.wa.us/planning 1�5016022=
Water use or limitation recorded................................... N/AQ Yes
Well Drilled ............................................................... Date ram_1
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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 6.68.090-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of Its intended use for the followng
reason(s).
��pp Reviewer's Signatures:
Environ. Health:V�71Y"u'✓ rm Date
CSDDirector: Date °`�
WATER WELL REPORT a DEPARTMENT of Naliceaf Intent No. WE54423 FF9 2 is
2i� III
ECOLOGY Unigve Ecology Well lD Tag No. BPO 119
Tspe of Rork: State of Washington 1/
0c ..on Site Well Name(ifmorrthanonewelly C
❑ Dasom a n b rengimiinstallatea NOl No. Water Eight PemtiUCerlificate No.
Proposed Use: aDemstie ❑l:tlmpml ❑Municipal Property pawner Name Aaron Bonnet
❑Donations, ❑ariprbn ❑Ten Well ❑Other
Well Stmn Address 7801 E GraOevlew Loop Rd
Combr*New well Type: interi0Dria:
m New well ❑AkerYion ❑Dmso ❑FenM 0 Cable Tool City Allyn County Masan
❑Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 12P2950-01002
Dlnremhn: Dametnofboring 6 in.,m 1W a. Was a varima approved for thin will? C1 Yes ❑No
Depthofwm levid well 130 ft.
Co.,ramm Marks: Wall Ifyes,what was the variance fats
Caring Liner Dr., From To Thickness ame, PVC WCBW Them
❑n 1 ❑ 6 in. 'i la 114 is ❑n ❑ ® 1 ❑ Location(see instructions on page 2): ❑WWM or❑EWM
❑ ❑ ❑ ❑ ❑ ❑ NW /yaofthe NE yq Section 28 Township 22N Range 1W
❑ ❑ iv. — — —m. ❑ ❑ ❑ ❑
❑ 1 ❑ in. ❑ 1 ❑ ❑ ❑ Latimde(Example:47.12345) 47.374429
l.origitude(Example:-120.12345) -122.831558
Perforxaom: ❑Yes ❑No TypeofperfernarusN
No.ofperinnuuns_ Sire ofper6mnone_is by OrUlar LoglComlrvcdov or Decommission Protedvre
Perforated n.m_J1 an ft.below grouts swface Families:Uncomic by color.character,site ofab"arlaM"Peore,and the kind aM
more of the abnormal in each hoer penetested,wish at least one entry for each cMnge of
SoreseP A Y. ❑No D K-Packer b Depth 122 ft. intenseness, Use sddhiopal slmns if necessary.
Monsfrcturer's Nam Johnson Material From To
Type stemen Meml N0.
Diaeter 5 in. slut rite 14 is,ftom?rt.m� Topsoil 0 2
m
Dome slmai n.from_rt.ro_R Light brown pay 2 35
Blue clay 35 39
SanmFumr pack:❑Yes ❑No size ofpnk nm.inl_in. Reddish brown silts and sand 39 57
Minna,,,heed Rom ft.a. ft.
Brown send 8 gravel wet 57 66
Sarno,Seal: IB Yes ❑No To what depth? 30 ft. Tight brown Sand&gravel wet 66 70
Morena,men info, bantpnaa
Did any roam canter.mm.bk water? ❑Yes ❑No Reddish brown sand S gravel some clay wet 70 ill
Typcafwanerl Depthofmw Tight light brown send 8 gravel wb ill 125
M.hodefsolingamma6 Light brown sand and gravel wb 125 130
Pvmp: Manufuv.er'a New 9OMS Type: sub
H.P. 314 Pump intake depth:100 a. D.Igrc4 Pow me: 12 apse
Wnmr Levels: Land-swfare elention abaw man ua kw,_ft
Stick-upoalocel 3casino_ ftebollwar, sDuar
Smkwamwaso 35' .,erg%bolowtupufwrll cesinp Dak
Amsun water
by anereimn Una
Amahn water i.emtmlka by mw.enlw,nc.l
Well ream:
Was a purnongtest personal? ❑No ❑Yes t=, Is'a mm?
Yield _Wre win_ft.anwde.after_his.
Yield _Wm with_ft.deawdown after_has.
Yield _Wm wi0_ft Mwdawn after_his.
Raaws,data Item-rum when pump is tamed of-ware,level me.utM fin.well
tap to water keel)
Time Wamteorl Tim Water Level Tim Wake,Lewd
Dam of rates; 8lese —
saikrrest 20 Wm with 50 fl.dmvtlownahrl ans,
Air test _Wm with stemm L_D.for_bra. Doe
Anesien flow_Wm
Tramrature oftener_°F Wn acM1cmiol malpis mdc? ❑Y. ❑No Start pate 2-7-24 Completed Date 2-15-24
WELL CONSTRUCTION CERTIFICATION: I con strpeted and/or accept responsibility for constructions ofthis well,and its compliance with all Washington well
construction sta sets.Materials used sod the information reported above are Use to my best knowledge and belief.
❑n DNIer❑Trainee Ill -Prim NAan'ce,♦E�mity Davis On any llivg Comp Davis Drilling
Simtamre YW VJ Add.340 NE Davis Farm Rd
License No.3142 City,Sum,Zip Beffair,WA 98528
IF TRAMEE:Sponsor's License No. Contractor's
Spanner's Signals. Registration No.DAVISDI11OOA Dam FEB 2024
F.CY 050-1-20(Rev 08/19)lfwa,need cos darumeml in an alternare faimat,Please call Ilse Water Resources Progn ea at 3,10 40--6872.
Pemm�s widt hearing Ines ten c411 A(Jnr Whshingfan Relm Sereire. Persrvas wai,a speeds duahilm ran call 877.433-6341.
Spectra Labs - Kitsap, LLC (Poulsbo)
J SPECTRA Laboratories - Kitsap 26276 Twelve Trees Ln NW Ste. C
mo«<.. Poulsbo,WA 98370
Phone: (360)779-5141
www.spmtra-lab.com
Spectra Labs -Kitsap, LLC (Poulsbo)received samples for Davis Drilling on Thursday, February 22, 2024
at 11:50 am. Unless otherwise noted, ail 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 Ili
237096-01 A-Borseth Well Head 02/21/2024 14:00
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
360443-7845 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 Spector Laboratories.
02126t2024 Page 1 of
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Grantor(s):(1) I "^• T A v t (2)
Grantee(s): (1)PUBLIC
Legal Description (1) (� I�d{,IC.�• I Tp.. Z
( bbn3viated form:i.e. lot, block,plat orsection, township, range)
Assessor's Tax Parcel: (1)L&-�a a-& V---Q.J—U Q a
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: y4 G
Maximum Annual Average Gallons Per D�ay: gallons
Dated on this � day of 1"l.Q/l�tf�l/�_.209"11
Signatu f Grantor(s): >.J
(1) (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
certifythat,.oqnthis 2% dayof pebrwajy . 20)-q .
m PcAi \ 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.
•• �w?�stir•Fy No Public in and for the State of Washington,
r+or 'g': - residing at D941W
2 ♦ uri
My commission expires: .Sc\,h9
•`IIIlflnpl\\"
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