HomeMy WebLinkAboutWEL2021-0003 - WEL Application, Design, Letter - 1/22/2021 •
Date Received:
MASON COUNTY _ 2 — 1
COMMUNITY SERVICES Arno t e®ived:o Received
Sa -
Fj` M Building,Planning,Environmental Health,Community Health �
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L a• I -0 603
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
PHONE
APPLICA T
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MAILING ADDRESS-STREET,CITY,STATE,ZIP GC)bcpv g pe_i/
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SITE ADDRESS
y'--�STREET,CITY,STATE,ZIP y� Q Q //��
PRIMARY4_NUMBER(WELL CD LA_
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SECONDARY PARCEL NUMBER(IF APPLICABLE)
22012 - 2 - qDD o
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
ew 0 Existing Well 0 Spring 2 I . 25
PROPOSED WATER SYSTEM NAME(REQUIRED)
VV I Lp GR.r u EYL
PROJECT DESCRIPTION
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DIRECTIONS TO SITE/CONDITIONS I 1 i ,�.--)
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CD t.1--VA--rb M u, 1 LAC.). 3- - to-- zryL, (27)
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
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Submittals Checklist: (these additional items will be required for approval)
❑ Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
❑ Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
❑ 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 form may be scanned and available for public view on the Mason County Web site. Revised: 1/17/2019
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
12-"❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is ro private, ounty or State.
What is distance to ROW? ?'4..5
❑ Does the ground slope away from the water source site? (show slope on plot plan)
r;}/ ❑ Is the well cap satisfactory?
L� LJ ❑ Screened and vented? v
El The well casing extends I t abo evel ground/co rete slab? (circle one)
[l❑ ❑ Is there evidence of a surface seal?L" ❑ Does the seal appear adequate? ' 1 7 0
❑ Vq
Is a variance necessary for well site approval?
Comments Li 1:k$12'� t -1'y'>.t�6 ti-I y to
Pass 0Fail Inspector �/� Date (.J? 1>0 VI'
Review Step 2: Two-Party Review:
YES DIO NA
L ❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
�❑. ❑ Received Satisfactory Bacteriological Analysis? Date of test 1 1 17't( 'Yo 7-
❑�❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN .?;' 1 ti ce 1 ko%
E❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
roved ❑ Denied Reviewer -e----e___________ Date 7 11 l o y
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express
or implied of the future success or failure of this system. Well site approval does not constitute water system approval. Water
System approval is a two-part process.
All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additional,fees may apply to all new wells drilled after January 19`", 2018 per ESSB 6091.
This form may be scanned and available for public view on the Mason County Web site. Revised: 1/17/2019
Page 2 of 2
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r s, 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON.360-427-9670,EXT 400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400
r 1 :, ELMA:360-482-5269,EXT 400
building,Planning,Environmental health,Community Health FAX:360-427-7787
07/07/2022
WILDERBUER THOMAS & BARBARA
11384 SOUTH MORNINGSIDE DRIVE
GOODYEAR, AZ 85338
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2021-00003
140 E COUNTRY BUMPKIN LN
220122390080
The 2-party water system, Wilderbuer Water System #2, 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.
If you have any questions, please contact me at 360.427-9670 Ext.353 or email at
Icencula@masoncountywa.gov
Sincerely,
Luke Cencula
Environmental Health Specialist
Mason County Environmental Health
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M. Halverson Design LLC Site Info: 140 E Country Bumpkin Ln SKEET NUMBER
9 Thomas & Barbara
PO Box 1519 Shelton Wa 98584 Shelton,WA 98584Vililderbuer
(360)490-6365/halversondesignllc@outlook.com parcel#: 22 01 2-2 3-900 80
WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE42117
ECOLOGY Unique Ecology Well ID Tag No. BHT 970
Type of Work: State of Washington
El Construction Site Well Name(if more than one well): Wilderbuer
❑ Decommission r) Original installation NOI No. Water Right Permit/Certificate No. N/A
Proposed Use: 0 Domestic ❑Industrial ❑Municipal Property Owner Name Barbara Wilderbuer
❑Dewatering ❑Irrigation 0 Test Well ❑Other
Well Street Address 140 E Country Bumpkin Lane
Construction Type: Method:
❑O New well El Alteration ❑Driven ❑Jetted O Cable Tool City Shelton County Mason
❑Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 22012-23-90080
Dimensions: Diameter of borin6 in.,to 207 ft.
Was a variance approved for this well? ❑Yes E No
Depth of completed well 207 ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
p I ❑ 6 in. +1 201 .025 in. E I ❑ O I ❑ Location(see instructions on page 2): l WWM or❑EWM
❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ SW %-1/4 of the NW '''A;Section 12 Township 20N Range 2W
❑ I ❑ in. in. ❑ I ❑ ❑ I ❑
❑ I ❑ in _ _ in ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.237228
Longitude(Example:-120.12345) -122.882691
Perforations: ❑Yes E No Type of perforator used ,
No.of perforations Size of perforations in by in Drillers 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: ❑O Yes ❑No E K-Packer ' > Depth 200 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson's Material From To
Type Stainless Steel Wire Wrap Model No.
Diameter 5 in. Slot size 15 in.from 202 ft.to 207 ft. Brown Top Soil Oft 2ft
Diameter in. Slot size in.from ft.to ft. Brown Sand w/Gravel(Wet) 2ft 43ft
Brown Sand w/Clay(Wet) 43ft 52ft
Sand/Filter pack:❑Yes ❑a No Size of pack material in Brown,Siltbound Sand&Gravel 52ft 79ft
Materials placed from ft.to ft.
Brown Sand w/Gravel(Wet) 79ft 148ft
Surface Seal: El Yes ❑No To what depth? 19 ft. Dark Brown Clay 148ft 156ft
Material used in seal Bentonite Chips
Did any strata contain unusable water? ❑Yes El No Dark Brown Sand w/Organics(Wet) 156ft 166ft
Type of water? Depth of strata Grey Clay 16ft 171ft
Method of sealing strata off Grey Gravel 171 ft 195ft
Grey Sand w/Gravel(Water Bearing) 195ft 207ft
Pump: Manufacturer's Name Franklin Type: Submersible
H.P. 1.5 Pump intake depth:190 ft. Designed flow rate: 10 gpm
Water Levels: Land-surface elevation above mean sea level 210 ft.
Stick-up of top of well casing +1 ft.above ground surface
Static water level 170 ft.below top of well casing Date 6/3/2021
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? O No ❑Yes • > 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 15 gpm with 3 ft.drawdown after 4 hrs.
Air test gpm with stem set at ft.for hrs. — Date 06/03/2021
Artesian flow gpm _
Temperature of water °F Was a chemical analysis made? ❑Yes ❑O No Start Date 05/18/2021 Completed Date 06/03/2021
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
❑Driller E Trainee❑PE—Print Name Drew Hall Drilling Company Knapp Drilling Inc
Signature D7 z,ov-7 a,,1 Address 50 E Lesaca Dr
License No. #3354T City,State,Zip Shelton,WA,98584
IF TRAINEE:Sponsor's License No. 1706 Contractor's
Sponsor's Signature DAM AO"Knapp'J' Registration No.KNAPPD1952B1 Date 06/04/2021
ECY 050-1-20(Rev 08/19)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 877-833-6341.
1
Thurston County Environmental Health
2000 Lakeridge Dr.SW •Olympia,WA 98502
► ..
360 867-2631
THURSTON
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
/Il a 7 ja/ Collected
Month Day Year J j phi
Type of Water System(check only one box) 0 Private Household
❑Group A ❑Group B 910ther' r�
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: May dfD - drie
Day Phone:(3(911 . >- q_ /U Cell Phone:( —)•
E-maitoivedTRetil ma•if.Com Eve.Phone:( — )
Send r dtto: nt full and zip Code or email address)
.hr 1 ferkt,
SAMPLE INFORMATION
Sample collected by(name): Mc j , ` , ram
S/peel`ciific location or address where sample collected: Special instructions or comments:
She 1174.1, INAOSt
Type of Sample(must check only one box of#1 through#4 listed below)
1.7outine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free_
❑E.coli-GWR(ANP)
❑Fecal-Surface,GWI.springs(numeration) Unsatisfactory routine lab number: •
Filtered:Yes No
❑Assessment Monitoring(AIP) •
Unsatisfactory routine collect date:
❑Other
S
4.0 Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and o Satisfactory
Coliform detected
❑E.coli present 0 E,coli absent j
Replacement Sample Required: •
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform_ 1100m1. E.coli /1o0m1.
Fecal Coliform I100m1 Enterococci /100 ml.
Method Code:rt SM 9223B ❑SM 9222D O to and e e ;' 't 22.0
SM 9215E ❑Enteroleri0 NuV
Date and Time Analyzed:(/ -Zq-2. Date Reported:I( Z tI i
Sample Number(DOH number plus rive digits) r Lab Use Only:
0 8 0 ( f_ t0 2
•
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Arm fmLnle r�arl rinses \ f