HomeMy WebLinkAboutWEL2022-00034 - WEL Application, Design, Letter - 6/22/2022 Date Received:
v MASON COUNTY ZZ ZZ
ACOMMUNITY SERVICES Amount Received: Received B :
ojh(J ,„ Building,Planning,Environmental Health,Community Health
-CD o
415 N.6th Street,(Bldg 8)—Shelton,WA 98584
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
GER111.-40 a ood Wey L • SOLCs 366 -- 55/ /6 5
MAILING ADDRESS-STREET,CITY,STATE,ZIP
SI ESS-S ET,CITY,STAT�4 &Ky v/,e� 4 (75 4
/50 5 55rek 175/a ioW ,VovM, Eta, eV/e4U k/4 '/851
PRIMARY PARCEL NUMBER(WELL SITE) /2/0 8 FSV OO 80
SECONDARY PARCEL NUMBER(IF APPLICABLE) A//4
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE /�
0 New Existing ,'Well 0 Spring
4- 5 4Gr�GS ^/
PROPOSED WATER SYSTEM NAME(REQUIRED)
A /f_5 Farr) , k/e//
PROJECT DESCRIPTION
6lAnfle.i1 shyle km;/y Ii /s r.s7L-eln to a Z-pry7Ly
/ ,CO), 74.E a 7zi or, erc 4,, 4Dv 6h sq y,.e, ihax reavre/
DIRECTIONS TO SITE/CONDITIONS
1r0rr» Noy 3 /'//aw Zer /Pa/ 10 /47.1e4y14711,91 . Cross
6Ki 7 e Sfi el-ch .27s/. ,47' 4 ii, q .
Aayse , ri h of 4o Off' h,//.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
Submittals Checklist: (these additional items will be required for approval)
atisfactory 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)
L� otice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
L. 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: 10/13/2021
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)
❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is 6 private, ounty or State.
What is distance to ROW? '36 b,Fj 6-
�0 ❑ Does the ground slope away from the water source site? (show slope on plot plan)
0---"0 ❑ Is the well cap satisfactory?
D' ❑ ❑ Screened and vented?
❑ The well casing extends �01 above level ground/concrete slab? (circle one)
[]' ❑ ❑ Is there evidence of a surface seal?
i ❑ ❑ Does the seal appear adequate? }� 1 1 1'
❑ El/ Is a variance necessary for well site approval?
Comments 11.34 I D i ) 0y}, c‘I'lli l q
[Vass El Fail Inspector [ Date (,)'gyp fye, 7-y
Review Step 2: Two-Party Review:
YES_, ,10 NA
❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
2# ❑ Received Satisfactory Bacteriological Analysis? Date of test 4. 141 lo-r ,'�'
[ III Received Signed, Notarized, and Recorded Notice? AFN ')-1 $ y 9
0o."--❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
eiPproved ❑ Denied Reviewer Date n'-(I 707-7-
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 19th, 2018 per ESSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
e �J`�N COUNTY
�Y 415 N 6TH STREET,SHELTON,WA 98584
SHELTON.360-427-9670,EXT 400
� �ro4 COIVIMUNITY SERVICES
BELFAIR:360-275-4467, EXT 400
Building,Nanning,Environmental HealthCommuukyFlooltlr ELMA:360-482-5269,EXT 400
in VW i. FAX 360-427-7787
07/07/2022
BOLES GERALD D JR & WENDY
PO BOX 224
GRAPEVIEW, WA 98546
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2022-00034
150 E STRETCH ISLAND RD NORTH
121087500080
The 2-party water system, BOLES Family Well, 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,
(....__,---y-- --
Luke Cencula
Environmental Health Specialist
Mason County Environmental Health
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MCPH RECORD DRAWING (ASBUILT) pg. 2
Assessor Parcel# 12-(0$ _—T S Ei G ••
RECORD DRAWING /
Drainfield&manifold kp�S�
orientation&layout /eo`
w/dimensions for
relocation. ` 4C
21 Trench/bed
dimensions and Q5 ""ice a ��
critical distances ObS J . �
within layout J,�—s A-A-
--- .(..0
placement
tank
placement ��'� G'.e�.,
fa Location of buildings ����
existing/proposed 7� O O (Z�►�
0.
Observation ports, 0 e^^"'� ��
dean-out locations, .,
&manHoids'd-boxes C,tir 4i \I- ,442_&BA p,(Cep`
laLocation of wells, Q 0
surface water,roads, r
&waterlines. O Cs) .fi(K ` L,s,e_.)
rgi --------
Reserve area(s) J
EfS.D(CeLr,- -Or,Q_ ar,�
North Arrow _ � �,�
If the designer or installer fee e need for additional informatio mentst it may be attached.
ra
Record drawing may also be n a sepe page-attached '�—CI No.Pages Attached
lEr-
CERTIFICATION •F INSTALLATION
INSTALLER DESIGNER
i certify that I installed the system in accordance with I certify that the system has been installed in accor-
the septic design stamped"APPROVED"by Mason dance with the septic design stamped"APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that all information contained on this I further certify that all information contained on this
form and attac awing is accurate. form and attached Record Drawing is accurate.
I L .2E,/7
Sig ure of installer Date ,41‘).‘V
V`� 1 3✓Y1/`�r�(� ��
.� ' \ "".. .V1 wway*'•9�.,Hl,
Printed Name of Signee 'N. • \h
p y1
MASON COUNTY PUBLIC HEALTH Z ere.
•
The undersigned approves this Installation Report and �Z .pgULA5JOY349 JOHNSON
Record Drawi on behalf of Mason County Public �' . .j.AULSE C?E tiGNC�f�" u
Hea h: e: E 1 rl o _
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01 I'i AUG 3 0 2017
Signature of Er onmental Health Specialist Date (designer's stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upd"ted 12172015
Printed From Mason County .
rated'from kt.oson County MS
•
WATER WELL REPORT CURRENT
Original&I"copy-Ecology,2"d copy-owner,3'd copy-driller Notice of Intent No. WE24796
e(PARTMENT OF
ECOLOGY Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No. BJT 912
sK�,�„�
® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION
Notice of Intent Number Property Owner Name Gerald&Wendy Boles
PROPOSED USE: El Domestic ❑ Industrial ❑ Municipal Well Street Address 150 E Stretch Island Road North
0 DeWater 0 Irrigation ❑ Test Well 0 Other
City Grapeview County Mason
TYPE OF WORK: Owner's number of well(if more than one)
Location NE1/4-1/4 NEl/4 Sec 08 Twn 21 R 01 EWM ❑
.l New well 0 Reconditioned Method:❑ Dug ❑ Bored ❑ Driven (s,t,r Still REQUIRED) Or
CI Deepened El Cable 0 Rotary 0 Jetted
DIMENSIONS: Diameter of well 6 inches,drilled 118 ft. WWM
Lat/Long
Depth of completed well 118 ft. Lat Deg Litt Min/Sec
CONSTRUCTION DETAILS Long Deg Long Min/Sec
Casing El Welded 6" Diam.from+1 ft.to 112 ft.
Installed: 0 Liner installed " Diam.from ft.to ft. Tax parcel No.(Required)12108-75-00080
El Threaded " Diann.From ft.to ft.
Perforations: n(Yes 0 No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of perforator used Formation:Describe by color,character,size of material and structure,
SIZE of perfs in.by_in.and no.of perfs_from_ft.to_ft, and the kind and nature of the material in each stratum penetrated,with at
least one entry for each change of information. (USE ADDITIONAL
Screens: ® Yes 0 No ® K-Pan Location 111 SHEETS IF NECESSARY.)
Manufacturer's Name Johnson __ MATERIAL FROM TO
Type Stainless Wirewrap Model No. Brown Top soil 0 2
Diam.5 Slot size 20 from 113 ft.to 118 ft. Brown sandy gravels 2 18
Dian. Slot size front ft.to ft. Gray Silt Bound Sand&Gravel 18 46
Gravel/Filter packed: 0 Yes El No Size of gravel/sand Tan Silty Gravels 46 75
Materials placed from ft.to ft. Brown sand&Gravels 75 89
Surface Seal: El Yes 0 No To what depth?18 ft. Brown sand&Gravel Water Bearing 89 118
Material used in seal Bentonite Chips t
Did any strata contain unusable water? ❑ Yes ® No
Type of water? Depth of strata
Method of sealing strata off — +
PUMP: Manufacturer's Name .
Type: H.P. -n
WATER LEVELS: Land-surface elevation above mean sea level IL —`C •
Static level 64 ft.below top of well Date 4/28/17 ri--t D
Artesian pressure lbs.per square inch Date r——
Artesian water is controlled by (cap,velvet etc.) t-" t
WELL TESTS: Drawdown is amount water level is lowered below static level rr-
Was a pump test made? ❑ Yes ® No If yes,by whom? cp •
�,
Yield: gal./min.with ft.drawdown after hrs. C,' 4::Z,
Yield: gal./min.with ft,drawdown after hrs. C
•
I Yield: gal./min.with ft,drawdown after hrs. ,.._
Recovery data(time taken as zero when pump turned off)(water level measured from
well top to water level)
Time Water Level Time Water Level Time Water Level _
Date of test q;r
Bailer test 15 gat/min.with 17 ft.drawdown after 4 hrs. f I ..
Airiest gal./min.with stem set at ft,for his. 'r , r1t•p f tc,,,Q,y t,
Artesian flow gp.m Date • �j
Temperature of water Was a chemical analysis made? ❑ Yes '' No tI ( S1 i tart Date�/20/17 Completed Date 4/28/17
WELL CONSTRUCTION CERTIFICATION: I construct@%),Id/or accept feeVdnlllbil4ty es truction of this well,and its compliance with all Washington well
construction standards. Materials used and the information reported a-1i0Ve are true to my best knowledge and belief.
®Driller❑Engineer❑Trainee Name(Print)Dwane Knapp Drilling Company Knapp Drilling Inc
Driller/Engineer/Trainee Signature . Address 50 E Lesaca Drive
Driller or trainee License No. 1706 City,State,Zip Shelton , Wa, 98584
IF TRAINEE:Driller's License No: Contractor's
Driller's Signature: en;r--- LC. -.�j( Registration No. KNA.PPDI952B1 Date 5/1/17
ECY 050-1-20(Rev 02-2010request ADA acconunodation including materials in a format for the visually impaired,call Ecology Water Resources Program
at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341.
rttttr
Thurston County Environmental Health
2000 Lakeridge Dr.SW •Olympia,WA 98502
360 867-2631
THURSPON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
o(O I/3 i 22, :50 N0,50n
Month Day Year l7 PM '3
Type of Water System(check only one box) CIPrivate Householk V
❑Group A ❑Group B ktOther_Fern/ t / f
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: /. - /
Contact Person: IIf.*4I 501f.5 ✓ " 5gq
Phone:(3 310 3737 Cell Phone:geo i
E-mail: ev/d0/e5 ,. ,/,, e.Phone:( —}-�
Send results to:(Print full name,address and zips.ode or email address)
1�c%&ZO Z. f,<)LE.S
__ EV/ V/ W4 ?8546
SAMPLE INFORMATION
Sample collected by(name): Wow/L ,
Specific location or address where sample collected: Special instructions or comments:
/50 6 Sfrekr.,4 . 'Pd/6/.
te905v ew U14 'p8546
Type of Sample(must check only one box of#1 through#4 listed below)
Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No El Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli-GWR(A/P)
❑Fecal-Surface,GWI,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other
S
4.1=1 Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
❑E.coli present ❑E.coli absent o Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform I100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
• Method Code Code71201A 9223B ❑SM 9222D Date anid Time Received: le 43
❑SM 9215B ❑Enterolert® "
Date and Time AnalyzeA' ° 'Z L Date Reported: b.(5 Z L
Sample Number(DOH number plus five digits) Lab Use Only:
0 8 0 t 3
• DOH Form#331-319(revised 01/16) .J