HomeMy WebLinkAboutWAT2024-00459 - WAT Application - 4/9/2024 / MASON COUNTY WAT
COMMUNITY SERVICES
&Hding,PY VEWmmeMlH� ith.Commundy Healtl
415 N 6° Street,Bldg 8,Shehon WA 98584,
Shelton:(360)427-9670 ext 400 O Belrair.(360)275-4467 ext 400 J Elma:(360)4825269 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: (-O L 6 6 A 44 J Date: Y/Zf�
Mailing Address: P, 0 . DIY` 212 & 6 Phone: $GO -'190 -28y-7
Parcel Number: M6 - 14-gooin
Type of Water System Reason for Application ,1 G
❑ Public/Community,Water System(2 or more X Building permit -P7o 2mq- QD0
connections) ❑ Division of land:
XIndivid al water source(one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ 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 PublidCommunify 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
This form may be scanned and available for public view at wwvv co.mason.wa.us.
rwH Fm \priv 9Wm ue...e 1/25RGH
Individual Water Well
r
Water well report(attached to application). Depth t yo R
Well capacity Test(attached to applicationgpm :�!U(() pd.
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)
Developmentwithin which WRIAhttp�//gis.co.mason.wa.us/planning 14IP15=16=22=
Water use or limitation recorded................................... N/A Yes EZZ
logWell Drilled ............................................................... Date
Individual Spring/Surface Water
❑ W DOE 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 33: Mason County Community Services Evaluation (staff use only)
oyO is detectory Deterrni t addres
(/ This determination does not address adequacy of the distribution system,guarantee an adequate supply of
Refer indefinitely in the future,or guarantee compliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,7Ne 6,Chapter 6.68.O40-Delertnination 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: �2-�1 1 `r^/ I `w Date Sj1j?'4
' 1
CSD Director: Date 2a2
�.p,�aba��y59
ENVIRONMENTAL
HEALTH RECEIVED
WATER WELL REPORT I= DEPARTMENT OF Notice of barn[No. WE55699
ECOLOGY Ud,gd,,,,,,,Wal11DTaRNo, BPF173 ePR 20
�pef�wa�rk Stale atwasMngeon Site Well Name(ifmore 8lan me xNl):❑ Decommission C On®' I Kmn NO1No Water Right PesmiVCenfnute Na. Cq J Alder " c
propml use ®Dominic Dhadomid ❑MOOeipl Propetty Owner Name Caleb Chakos
D Dawaekg ❑hnparkm DTN wNl ❑Other
Wall SIIM Address 81 SE Sister Meatlaws In
emer -1 Typ: staged:
O Nee,w wel1l DMeraian ❑Qua ❑tend ❑Cable TOW City She,on County Masan
❑Deena, ❑Odwr O Dug MAN, ❑Mad.Roary Tex Pemd No. 319041490)10
Dleemlos: Duawnm OfMmkg 6 u,b 142 A.
W
DePhaf.maleadwe11110 A. navarieme approval far this;well? ❑Yu ❑` No
Connemara.Details: wad Ifm what was the returnee W.
Caere, Liew Dina Team To laklmae SIW PVC waidd Thetl
ON 1 ❑ e a. 0 137 .25 in 13 1 D 19 1 ❑ I,oetawn(me matruelisssan Page 2): 13 WWM m❑Ei1M
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❑ 1 ❑ _eta. _in ❑ 1 D ❑ 1 ❑ Istitude,(Example;4732345) 47.16734
ParRrerons: ❑Ynn ONe Tycofpulamured LOnBilde(Example: 120.12345) -123.a5789
No.dpafatonn_ Sheofpolanoa_b.by_is Driller's LogdCOostrucroa or Decorate Praadvre
Poebnnd(mm_h.b_Rbebw Fmsd au9ee Fomemion:Deenhe by color,ahucm,aivatmmial coal munun,and me lnw.d
murc ofac memd'weach kyapmheW,wiN az Imam entry fmannhchsige of
Scrams: my. ON. mK-Palter b Degh 134 fl. o6vmeiao. Ov edtimiarul siwae ifneaawy.
Mtadsoere,xim,ANov Mesdine Works Material From To
T}y WfirOWrapped MWdNo.
Di. T Setrke020 intern In Rb140 R Gray fire to metlium silWOulal gral.tlht,tl 0 8
Diemmr_ sM."te_ie.dam _Rb_R Fine to medium routs gravel anal eaame,sand, 8
saaNFaarpakoYes ON* Seofpd:us:l_in dry 25
Mamuk paid fiwe_Rm_R Gray fine to medium ally smal and Amesal 25 30
suecoe seal: Ores ONO Towlmdgth119 A. and
fine to medium ell band and favel,tl 30 52
Material nned in rat Bentonfte chip. Brown fine to medium si sarq an0 ravel,leads 52
Did wry eoeu ennain me—ble wwr/ DYs DNo m01s1 64
Typeefwata(1 Depth.f. Brown fine to medium sand arts greasit,heaving 81
Mated ofsealms maaaB Was.Red 95
Blue manq sift 95 90
Pump: Monuhmmer'a Name Tn. Blue stickyday 99 121
NP._ Pw:p iaake deph:_fl Damewilowone:_gpm
Gray fide sandy sift,veins of gra,al 121 133
Waarlreb:Isd�mrlece<kvako above mean sn kwl 195 R Mutfi�e010(Bd fill,to medium gmwi and gray 133
Stab ofnopofwellcaeb, 1_6 9.above 9omd aw9a Sand,water Maring 142
gnak were level 80.7 R.6,,W deolcealm DW 415124
Meson p<m:v<_Iba.prgmairc5 Dam
Maine wem iaanm0ed by (ap.vrls.eaJ
Wall Tea:
We a Punpks tea par mesa? RNo ❑Ye C by whom?
Ykld_g mi wWe_A.tlnmccam.fiat has.
Yield_rem woh R.dnwdowo a,a_ha.
Yeld_p nn aim_A.enwmwo efts_lea
Raaray deu hime ssro real.peq u lamed off-.kwl waned mom well
lopbwtar roi)
T warri—el Time waalawl Time Well Laval
DMorpmmmmg con
MIN,Na_Stan with_A.deardawn.Ri_bn.
N . 25 g seeiis et®m.e 120 a.ur 1 hi. Dar VW4
Are im,ow_rpm
Temparess Otmmta 52 •F Wmachemealaaelysumlude? ❑Ynn ON. Start L7k 4/5/24 ComphoM Des M524
WELL CONMUCnON CERTEFICATION: 1 consDued enNor accept respsulbility fm com,lanim OfNis sail,ad its c0mpliaru with all WsshinlIIOn will
conNNdlonslamvJards.MakridsusedmWdieinfomution.pWdabovemeuuebmybestkno Mpcoalbelief
❑A 11`a Trei a PE-Print Name Co Johnson Drilling Compury Atcatlia Drilling Inc
md Siure y Address PO Box 1790
u.No.A.,IT' Ciry,Soak Zip Sheftm.WA 98584
rF TRATI .S sa's Lj..NO 205E Contractor's
Soonre's Sigsme Registration No,ARCADD1098KI Dos 41524
ECY050-1-20(Rev09/18) UyaN nadlhU dmxvncem in coon a8ematefornm4 Please mB dce WarerRemmces Pmgnmm360-107-d877.
Persona wfthM n,,roes con call 711/or Wa rgmt Relay Savfet. Persoecwlihos whduahllfrycmmeal18774334341.
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' `WATER
MANAGEMENT
ENVIRONMENTAL LAS0RATORIESuaa.� RECEIVED
HEALTH
�pti�$ tA APR 18 2024
Deb Saale Cetleded 91M Swnple Cwmly
{ I 4 e AA nSO� 15 W. Alder Strc;
TM0fWaWSyalem(dwdoayaneborl
❑Gw,A ❑G.PB
Gmup A sad Gmup 8 Syalems-Pmvlde man West Fades,hvet"(WF*
IN
Syalem Name:'( �'� t j<.D
ConmdpemonAtcadia Drilling, Inc
DWPhww:860 ) 426-3395 od PAma:( )
Finab Ese.Powre:( I
sane in6 tr tMhd M ame,mews..wd eo esal
Arcadia_DSM:Lng, Inc
PO Box 1790
Shelton,. KA 98584-
. .... _ SAMPLE IRONWATfON rti.
Sample mlreded by(rema): C
figsB but.e we sample wleded: SpedellwWwomwaxnmeMc
Se S (.s *oJow kj in
TypdofSomOt(RIM Wily 4 We.ursamp7i from lypoetyuv gn 56ebw)
1.❑Routlne Dlsfit0lm Sample IAIPI 2.❑ Repea Sample(AW)
Chlomaled;Yea_No__ pmmd+aNiwmelnwnatlwweee nwtlnw
Unsadelacbry mudne leb mapem,.
Chbme Residual:Tole,_Fme_
S.OmmM Water Rule Souris Sample
Unsetlnleday mums wlbddare:
ChUkMW:Ya_No_
❑Tdppered(kP) Qlaxe Re al:ToWL_Fla_
❑Aeeeamed(A?)
d. 8udaa mGWl Raw Source Wamr Semple(Eiwmeretlm) IQQ IIII
❑E. ❑Fecal smw.e x.._sp._._
iMw SangM N kr Wxemwon Onty:
,SAS IISE ONLY DRINKING WATER RESULTS L9B USE ONLY
❑UnaOcyemoy Told Wits. meenland I 8Mmtatoq
❑Ewfl Msent El COO obesnt
Bectxlal Dealty Rases:Tdml CoYbm M00A. E.md-----t(x3W.
Fowl CoNom M00d. HPo Nae.
Raplawmmt Sample Raq.lmd: ❑TNTC . . ❑S&NNOWC61
❑ 8appla Vlore ❑Demm9ad Cgnl0W
D. Wwmiiars ea V
pedmlTemgC MM^tl V
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DgIWRamblee
089c'y
oevtlM W bY.a.e.YY.tlwn.W x¢vmr Y�x
ENVIRONMENTAL Arcadia Drilling Inc.
HEALTH P.O. Bo:1T90
Shelton,WA.98584
Customer: Caleb Chakos Well Tag#: BPF173 RECEIVED
Site Address: 81 SE Sister Meadows Ln, Shelton Depth: 140'
Date of Test: 4/8/2024 Static: 81.9' APR 18 2024
Pump Set: 120'
TIME GPM LEVEL I RECOVERY 5 W. Alder Street
1 Min 7 84.6 TIME LEVEL
2 Min 7 85.4 1 Min 86
3 Min 7 85.6 2 Min 84.1
4 Min 7 85.7 3 Min 83.4
5 Min 13.2 88.9 4 Min 83.2
6 Min 13.2 89.1 5 Min 83
7 Min 13.2 89.2 6 Min 82.8
8 Min 13.2 89.3 7 Min 82.8
9 Min 13.2 89.5 8 Min 82.4
10 Min 20.7 1 89.7 9 Min 82.3
15 Min 20.7 93.9 10 Min 1 82.3
20 Min 20.7 94
25 Min 20.7 94
30 Min 20.7 94.1
35 Min 20.7 94.15
40 Min 20.7 94.2
45 Min 20.7 94.3
50 Min 20.7 94.4
55 Min 20.7 94.4
1 Hr 20.7 94.5
1 Hr 10 Min 20.7 94.5
8�pa��oow�I
Return To 2209662 MASON CO WA
CHAK052024#1966315Rec Fee 0$306 50 Pa9es 2
RECENE,:-,
APR 18 2024
615 W. Alder " '
Grantor(s):(1)f ��fjl/'CL l� ![K�j . (2)
GraMee(s): (1)PUBLIC (' ,-I f�
Legal Description (1) Lz 1 L 1 0 Y �4*015 1 AM: 2.1$'$�ICi$� Fir n of7EQ1�
I(2Abbrevi-aW form:I.Q.lot block,plat orsection,township, range)
Assessoes Tax Parcel:
TITLE NOTIFICATION OF WATER RESOURCE INVENTORYARFA(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.
Maximum Annual Average Gallons Per Day: gallons
Dated on this day of ( i.OT 202±.
Signature of Grantor(s):
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 iday of APr�I .20 a4
ZRSStoc. CYv.IcoS personalty appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she)(they)signed R.
GIVEN under my hand and official seal the day and year last�1above wrwritten.
'Qe&tea- t7I.0 14-0
Notary Public in and for the State of Washington, v
residing at USD E 'Tetyy%M+- Dr She 140 USA- 4&sgy
My commission expires: 04-dta-90atP
a so are u or
Notary Public
State of Washington
My AppoinM5nlPxpirfis 912612026
Commission Number 22pJ0666
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