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HomeMy WebLinkAboutWEL2024-00020 - WEL Application, Design, Letter - 3/25/2024 MASON COUNTY 415NB SHELTON: ,BHELTO70,EXT400 $HELFAJR 36G-2754870,EXT400 40 BELFAIR:360.2T5-A467,EXT000 Public Health & Human Services ELMA 360482-5269,EXT400 FAX 360427-7787 RONNY CLARK P.O. Box 3009 SHELTON, WA 98584 RE: WATER SYSTEM PERMIT:TWO-PARTY WEL2024-00020 1031 SE Arcadia Rd 320282200020 312812024 The 2-party water system, Clarcadia Water System (3202822000201320282200010), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater management around the water source. Condition: No development may occur in the areas logged under FPA# 2420872, issued by the WA Department of Natural Resources. This development moratorium is effective on the date of issuance, 03/22/2019, until the 6-year development moratorium expires on 03/22/2025. Any development or construction for this two-party well water system must be in accordance with the moratorium resulting from FPA#2420872 and RCW 76.09. If you have any questions, please contact me at 360-427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely, e//Z--- David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY COMMUNITY SERVICES -- --- — i15n64 I (BN16NI SM1 It ,WAOnSAa iWEL .10aQ CM2—C/ TWO-PARTY PRIVATE WATER SYSTEM APPLICATION aRE awnEas-smaT,rnr. nlem eel 28 2_2n0002 DXDMYYµCEL NYNBFA rIF aPPllcaahEl 7-0Z.8 06016 WPTERBWRLE BWPCE iYpE ❑Ncw LIYGxistin vzacau Lm slzE paRceLzwTalza 8 �Well ❑Spring WIDPMEDw41En aY8TEM x/,INE InEOuatEol /lam arco IAA{a{a iWMECi DEBCNPTIOM DInCTRIx9TO ME1<OXDngX9 '�.�: - __ By Site Plan:(may also be attached) IPmperty bounaaeiea,structures,wall site we100'retlixa.Cnveways.roaGa.swt«:hewer comporents and lines,easements,ele...j p'Ps. tee IRvP- -L`k 'b � Lui Stjs 4 o f S ri 'r.t IL O Sapau TMk Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deterred if well is not yet drilled) Well Log with pump test or 4-hour capacity test performed by driller(this may be deterred if wail is not yet dried) Notice to Future Property Owners recording (record with Mason Co.Auditor,supply copy of recorded document) Septic Records(additional locating requirements may apply if there is a lack of septic records on file) This fam may his aunnad and avallele ra Public view on the Mawn Ceumy Web site, Revised: 10/13/2021 Page 1 D12 Review Step t: Well Site Inspection: 1,r,f -I 5 Vi (4' Hy,Arat, A't Cw 4y C'"I[ 1 q✓+�R rAa? er y'l sw YES NO NA _ ,� '4 4-01 El Evidence of existing sources of con mination vi m 100 foot radius of water source? (drainfieids,tanks,buildings: indicate distance on plot plan) ❑ ❑ Are there roads within the 100 footrl dius of the water source? If so, is roatl twat County or State. What is distance to ROW? V ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) r vt (of. '❑ Is the well cap satisfactory?_ q cQpp `1z pvrr(et 4f y 64111140 / ( We IWh %eq❑ NZ El Screened and vented? _ Mini +t •"11'1 Q 007 Wily ❑ The well rasing extends g above level ground/ilEnirete sla (circle one) t p5� ❑ ❑ is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? ❑ � ❑ Is a variance necessary for well site approval, TQ Comments At if'o ._ KNmic ck*w _(f_ k ii! ; p( IV Pass Fail Inspector c9/// L/ Date Review Step 2: Two-Party Review: Y S NO NA ❑ ❑ Water Well Report with adequate pump test on file? A/C'aLlrcl PT!!r✓I on tZIL,7(1 qt vir 3O0M 41' 9 66" (1rf44 V) If NO,date of Capacity Test Z/9/20W Driller U Gd'✓A IIMI Pti' " _/k4/h fir jef, ❑ ❑ Receivetl Satisfactory Bacteriological Analysis? Date of test �p.ZQT ❑ ❑ Received Signed, Notarized,and Recoroad Notice? AFN Zu) Q f q (� ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments �11IY�Aft�►IP �,Q(/}�(� 3� tI Approved Q Denied Reviewer Date Findings in tha review repecr observed crrdinao,as lhev existed on the day of the site inspection. No claim is made.express or implied ofthe future success orfailure,oftFis swtem. Well site approtwl daes ear cnns'dmte sweet system apprnwL Water System approval is a teen-part pre., All,empm'ed connections to ri weir are subject to water adequacy requirements at time of Gadding pemtit perMCC 6.6$. Water usage restrictions and additional fees may applo to all new wells drilled alter.tanumy t 9", 1018 per HSSH 6091. This form may be sramwd and available for public view on Me Mason County WeD site. ftrrised: 10,13I'021 Page 2 of 2 Tle Otl[41al.nd Plnt Copy w'w AppYcanon No. ll,pone:AofRoollo9.copy WATER WEI1 REPORT TbW Gpr-Dmlere Copy STATE OF WASMNGTON Permit W .. Copy C .. (1) OWNER: hs..7.!_f L• ti�lbslei�.__ ,wm._iRl ........_VV.....7._uh�a�rlsa,_.,._O(,/a.�__...----------._./ to 2) LOCATION OF WELL: countr._ l.M1r_Yt___ ____-...-Jr-�4S 1/-•Yf: Bec�..Y_T� N.R... O N-tea and dl.twa.tram wcaoe or.nRx.woe eomer 3) PROPOSED USE Dom..xe p/bdo. ❑ eomxPx❑ (10) r�1WELL LOG: GRptbn ❑ T. Well ❑ ONR G .b�tMekM-�epmrm an,d t�M klr�M pe, aimun e000 %M maY.W In�tlek y a.mv-Pw.rw.d,ww u l.mt oiN emy In.wn cn.nv. pl Iv.u.xrn. 30 TYPE OF WORK: owner.numb-O' w __ _____ ttwTaauAy Hatt To . ) Tn a N., -eel.... .._.....__ . . H N.w well 0 M1LtROd: Du{ ❑ Boyed D peedDA❑ Gble � Orlvav ❑ ' �a a-ormbUowd❑ Rar.r>❑ T.Red ❑ /� ar. C 0'5) DIMENSIONS: uume.-Of w.0 _..._.__ 6, . . mm-. / G C nrwaa_�S•-Z-s, u m oemPlerod weu__.Zr£'Lx O is 6) CONSTRUCTION DETAILS: E C&sW LNItalled: pT ded❑ _ _ Dum. w.ld.d it .—." RLm. C QI Parfo atTOne: Y-❑ Ne K - yS M Pe orator p.tl- —• SUE ol p-eor.eou _ Im by — 0 perbrattooa tm apey,,N. .amen R w n• 1� Sarcoma: Y.0 No IO 1LnWamm-•.N.m 0 1aotY NP caua. N Dlm —trot Yv Gam--R.to�.R �? Gravel patked: Y-❑ -e L C La O-vl Pue.d ` tD u. jSurface leak ye, . NaQ T wb.) dwal '� pd .nr xr.0 roetm bl. w.t-1 V-'O O ttweoa o -x+er m.m Pe-- — r c' Z W N F/, rid N (7) PUMP: aa.ew..rm-'. N.—A C �: _ — T(S) WATER LEVELS: ,pP,eSin°Y1P1`m-eCewiwaLLi°... __ - p axe.mP m w.ti cr vsm, wr• _- O t-b DaM--_�._ Q Art.tl.v mw U mntoned by Ic.P.v.lva.am.l O LU (0) WELL TESTS: b"tea a 1°Nxaopt +�t..at t. wort �-S li pter.d-/. '1 -z--•t►� Ow-.pomp t-tmadet Y-❑ DRILLER'S STATEMENT. Cnxd: xJimtp.wub 'R.-a-wd.we attar t-. WI Thu d e to well was dtnled under--le my nd b.Ufm and lhla rePlat Y true b the best of my �pwiMae ontl beLLet. L Recovery e.0 (,00, liken u vry ob. PePm mre.d oRl. Iwat- ]eN ///� R me..ar.a Qom wm mp m waur Unody NA6D._� art4n.-02-K.//.tL... ITyps l../.V...!. .__.... G (Pawn. m,or mdiporarbn w pintl a rw Wmn tmi n-. water wau. r p....t e .............._.__.. IV '----.___--- . . ..._._ .............._............—__.---- �t [Sinned . _._..... r.wd lWW DxDerl niter-tee—�iw tb-� °'°" � �� Amex--eow -(.Pm DNe_-__ LL'' ... Date.!!" ------le - Temper.mn et waW---Wa.Wmrnl.exYx.made)Y-O No Liceme NP.....__ ...Z...77. IUar ADDITIONAL 'a a.r.Na.Td14-0e-19ay.4Tl1. COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 360-830-9005 COOL WDI941 QM ---rtF, . CUSTOR NnME DATE-2-9-24------ ----- RpV CLARK CUSTOMER ADDRESS 1031 SE ARCIDA RD TIMF. TTATIC GPM TIME STATIC GPM -- i 1990 - r25 -f96 193 _ 14 120 1% 14 i% 1�4 135 1% _ 14 196 14 _ 150 1% 1.4 196 14 t65 196 , 14 __ 14 180_ 1% 14 30 196 14 205 196 _ 14 __.. 45 196 14 __ 220 196 14 60 196 - 14 235 196 14 -- 75 196 14 245 196 _ 14 90 1% 14 105 196 ---- -�-- - RECOVERY STATIC RECOVERY STATIC TIME 196 - TIME_ y OS 191 30 15 ..... 190 45 _ 25 --- 190 --- 2627u Fw S.c SPEC'FRA Lbmatwiu., Kit,ap PW, ,WA 98370 (3W)77c5141 COLIFORM BACTERIA ANALYSIS FORM OG�A o0upe Do- Gmup A IN Crop—BSy� lmm (ff I I ma —Ek Day Fbme (a eYSa. ,e,e 5 SAMPLE INFORMATION i. *�.�by(�.Y, ftcrLt✓fi-f4{ Mop u r, tavj 4 Udm C) E[ [If" LAS USE ONLY ONINKING WATER RESULTS LAB USE ONLY 11.1 •;li E W RWNPm ;MmW Rpuaw: 0 4C 1-3 i D.T- It~ 4!K 2208943 MASON CO WA RON" C Ror LBPKlV, .c Fee 59.n 50 P, 2 Illildll l'I lulllllllll6lllillllll IIIIIII ll�lilll�ill�lll I Return To javmy Grantor(s): (1) 0-MN4 r{L Grantee(s): (1) PUBLfC Legal Description (1)-rAM fAbbreviafed form:i.e. lot, block,plat orsectlon, township, range) Assessor's Tax Parcel: (1) NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned grantor(s), certify that the water source located on the above-described real estate under Legal Description (1)and Assessors Tax Parcel (1) situated in Mason County, State of Washington, has been designated to serve a source of water to the following parcels situated in Mason County, State of Washington; herein described: Tax Parcel: (Connection 1) � $ 0 2 8 _Z Z-_0 a 2 0 Tax Parcel: (Connection 2)3 2 ?- ie� - Z 7. O ,� O 1 o The system owner is responsible for keeping this system in compliance. The name of the water system is: This system is designed to provide for two service connections. Planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Additionally,a water right, obtained from the Department of Ecology, is required if the water system exceeds exemption standards. This system (has/has not)been granted one or more waivers from specific provisions of the regulations. Dated on this ZS day of MR✓- 20?-'/. Signature rantor(s): 2) Page 1 of 2 State of Washington ) County of Mason ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby certi that on this ZSday of LA a V f k , 20_{, _personally appeared before me, who is known to be signer of the abbve instrument,and acknowledged that he (she)(they si ned it. GIVEN under my hand and official seal the da ar last a �9....0111 ra ry P�blic in and r the State of Washington, ti? o-�o �%4., mmission expi es:_s—w ' 7 �0io pr 0(AAY it Page 2 of 2 �{'IGr�T �� AS '3tt.tl.T' tWN C;CAtX- ! .�GCA�DLA zo ��/ SNfi�OJ t VJA 8 3?1 - 22- Oo©ZO �2LA�rA � 3� co 5 ,; G� g & L /0Q -o rs M W W Printed From Mason Couw kj°""le Printed from Mason County DMS �/