HomeMy WebLinkAboutWEL2022-00032 - WEL Application, Design, Letter - 6/14/2022 MASON COUNTY Date Received (12 _kg -0
D.
'il COMMUNITY SERVICES Amount Received: Received By Isn
%, Building,Planning,Environmental Health,Community Health
,.sic ea'•`w
415 N.6t°Street,(Bldg 8)—Shelton,WA 98584 Y Y E L (30 .a _ 06,i3 a
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT Pat, ! S�I,\im 1 c.9 PHONE /7 S 385 024'7
AB N-D11 0SS-STREET,sk) Y,S;N-E'Zr �1� 1 c \.�� �� .17
7 I
t etMOttn
SITE ADDRESS-STREET,CITY,STATE,ZIP / .+ `O I� L y/(� t{,,,'�
36 S Z F . it iw.5 A)E 05 1-�N t. . �= v.J A' 1 6 5 V
PRIMARY PARCEL NUMBER(WELL SITE) r
ZZ 12,52-39 OD I 2--
SECONDARY PARCEL NUMBER(IF APPLICABLE)
2 2_12-S 23 1 co a 1
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
rKNew ❑Existing XWell ❑ Spring 2.ZG2 2, 1 "�
U 1
PROPOSED WATER SYSTEM NAME(REQUIRED)
Se-4-1 rv1 (ES l AI 6c
PROJECT DESCRIPTION
Welt W0.4- -4r 10 "S 1 dr 2-- )
30So 4- 36 'Z F. HA R55c. .tir ISM/.Q0 1 .1 I, 5i'.,e1IF0i RA
-
DIRECTIONS TO SITE/CONDDITIONS { r tt h
1-re,nil lAe.,j yin' e 15LAA c� glaicC-a , L,. o&,1 1_ J�1drJ-L !, fa,,j !) ,
i. , &&) (' Hw'54't-u is/cvc\ R !J , j, Q '220 c...:Lc_ ' Jout h 60 I .,,, t( U4 L,
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc...)
W G''-.:7
-15
t
N 4 0
Submittals Checklist: (these additional items will be required for approval) N
IV
Vi
0 Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) C` '7
0 Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
0 Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of recorded document)
0 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 1of2
i
1
t
I
1
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO �PdA
❑ [� ❑ 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 NO radius of the water source? If so, is road privat ounty State.
What is distance to ROW? l be'1 o' e-- �✓��►-c+-3`'� '1 'ab O R -
ZIA ❑ Does the ground slope away from the water source site?(show sfbpe on plot plan)
1;176 ❑ Is the well cap satisfactory?
�❑ ❑ Screened and vented? -�
❑ The well casing extends 6 above Eel ground/c ncrete slab? (circle one)
Lr ❑ ❑ Is there evidence of a surface seal? A. GJ�
II ❑ Does the seal appear adequate?
❑ �j�/❑ Is a variance necessary for well site approval?
Comments 1.'),./c,c531 c>-).•c.16-11 S 4 6-1 61
Pass ❑ Fail Inspector Date L,B'?"yy"),
Review Step 2: Two-Party Review:
YES O NA
❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
❑ Received Satisfactory Bacteriological Analysis? Date of test 51s �1"),
El Received Signed, Notarized, and Recorded Notice? AFN 1�� ( I y
�❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
P-Iroproved ❑ Denied Reviewer _ Date SA=6l'�'Y2
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.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site. page 2 of 2
o._ A 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT 400
COMMUNITY SERVICES
BELFAIR:360-275-4467,EXT 400
g ELMA:360-482-5269,EXT 400
.p wi 6uil�ing,Plannirey,Environmentzlllealth,Communityt4ealdi FAX:360-427-7787
06/30/2022
PAUL SCHMIESING
19740 NW NORTH STAR DR
BANKS, OR 97106
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2022-00032
3682 E HARSTINE ISLAND RD NORTH
221252390012
The 2-party water system, SCHMIESING, 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
File,Original with WATER WELL REPORT Notice of Intent IA/"I 7 7 977
Department of Ecology UNIQUE WELL I.D.#AG E 552
Second Copy-Owner's Copy STATE OF WASHINGTON
Third Copy-Driller's Copy
Water Right Permit No._
I. l u 4.9.41 hrsorh:hgS'ibje_ ,r,.
Q. (1) OWNER: Name JJAN Pa/f Teod Address Aun1 lin. #bn k4.0LA cc 9a.4doe
w A� ,
Q (2) LOCATION OF WELL:County M QSO/4 S Y(/ 1r//4p .-.1//1 Seie([�,T .�1 N.R. 2 WM
(2a) STREET ADDRESS OF WELL:(or nearest address) t trS 1/rt c .ES /r.1 t A`1 P
TAX PARCEL NO.: as 12 6'2 3 0 OO 1 0
(3) PROPOSED USE: K Domestic ❑ Industrial ❑ Municipal 00) WELL'4LOG-'or DECOMMISSIONING PROCEDURE DESCRIPTION
_ ❑ Irrigation ❑ Test Well ❑ Other U _ Hnati�n:Desci b by color,character,size of material and structure,and
,C El DeWater )the'kind and nature of the material in each stratum penetrated,with at least
4.10 one entry for each change of information.Indicate all water encountered.
C (4) TYPE OF WORK: Owner's number of well(if more than one)
O x New Well Method: MATERIAL FROM TO
❑ Deepened ❑ Dug ❑ Bored �4H rc,�G( 0I *
C ❑ Reconditioned Cable ❑Driven L
o 0 Decommission ❑ Rotary ❑ Jetted h t
L�'OWt1 �fJF2✓1_ I /al
zrz
/ lit l 3B�'
t0 (5) DIMENSIONS: Diameter of well�p inches ?r0. heel"'
E Drilled / 7S feet. Depth of completed well / 73 ft. Gret. Ge64.ie h I Y ha c :a✓j 7R- 5
O (6) CONSTRUCTION DETAILS ?' ha/'dreci , SS
is—
C Casing Installed:. / C(0. ^Set etd" y/'rt V e tI 4 d t r
1.
6)(Welded . Diam.from-1" I ft.to / 72. tit. yam`, �,jets/ 72 1 2,ii
a Li Liner installed Diam.from ft.to ft.
_ yr 7 t
.+ ❑ Threaded Diam.from ft.to ft. 'ha Gt4 i y S d Ca`I +� 1 241 I I O I
L 7r4` Firs c sct —c lay (�rv' t is 0
O Perforations: ❑Yes (�,(Jo / c�N et e I L O ` 7`3
CType of perforator used
CU SIZE of perforations in.by in.
- __perforations from ft.to ft.
4.1
CU
CI T r
O Screens: *es D No ❑K-Pac Location /G 2 ��l (C F 1 V FE ID
Z Manufacturer's Name
's', Type .5 Mc in I'Ps,s S T«( Model No. t
Diam. S'1 Slot Size /p from / 72 ft.to /6 2- tt. SLP 2 ?uU4
C Diam. Slot Size from ft.to ft.
LILY/Atli ioni uret,l,Lubr
L ici 1 nnrt,!top,unnt
S.. Gravel/Filter packed: ❑Yes (XNo ❑Size of gravelsandco
1. . .. -.
Z. Material placed from ft.to It.
Surface seal: 1,es ❑No To t de ? �1�T ft.
Q Material used in seal Lfe#1 Q'kl ['
Z Did any strata contain unusable water? ❑Yes l'CNo
Type of water? Depth of strata
0 Method of sealing strata off �r_
'D (7) PUMP: Manufacturer's Name .e La. lU.S '
>t Type: SG(b. H.P. I
O (8) WATER LEVELS: Land-surface elevation above mean sea level 3� ft.
O Static level 3 2_ ft.below top of well Date fJ^J310' Work Started I ,0 9 . Compieted$_`0 , 04
O Artesian pressure lbs.per square inch Date
LIJ Artesian water is controlled by
41.. (Cap,valve,etc.) WELL CONSTRUCTION CERTIFICATION:
- - (9) WELL TESTS: Drawdown is amount water level is lowered below static level I constructed and/or accept responsibility for construction of this well,and Its
Was a pump test made? Yes ❑No If yes,by whom? dr,,/)eV compliance with all Washington well construction standards. Materials used
a , and the Information reported above are true to my best knowledge and belief.
E Yield: 2.0 gal./min.with 3Q___ff•drawdown after / hrs.
Yield: gal./min.with ft.drawdown after hrs. Type or Print Name grY,q 4e II C(vl S License No. 2 6 27
s_ Yield: gal./min.with ft.drawdown after hrs. (Licensed Driller/Engineer)
O Recovery data(time taken as zero when pump turned off)(water level measured from
0. Trainee Name License No
O well top to water level) •
Time Water Level Time Water Level Time Water Level Drilling Company W CS 6-I'GSS bt e✓ QNy//1 ,
o (Signed) ut c .t.l.ts. License No. 2 G 27
.0 J_. (Licensed Driller/Engineer)
Address PO aok t-b5-7 I7arIey rv4 91-322-
Date of test
Bailer test /6 gal,/min.with 215 ft.drawdown after I hrs, Contractor's 6 nn
Airiest gal,/min.with ft.drawdown after hrs. Registraticn No.W gSG 1-✓ rig 2.P6 Date g' 2 a , Qte
Artesian flow g.p.m. Date (USE ADDITIONAL SHEETS IF NECESSARY)
Temperature of water -0 .Was a chemical analysis made? 05;es ❑No
Ecology is an Equal Opportunity and Affirmative Action employer.For special
accommodation needs, contact the Water Resources Program at (360)407-
ECY 050-1-20(11/98) 6600.The TDD number is(360)407-6006.
Please print,sign and return to the Department of Ecology d J%e S v
(2—
Courant � � �(� `` �(L�
0 Water Well Report W186377 �� -�s
Original -Ecology,110c:py_ne es,Yicapy-dreier CurNotirent
ot Intent No.
E.ttrl'Hii l Unique Ecology Well ID Tag No. AP.B767
C On stria di on/Decommission
Q Construction Water Right Permit No. EXEMPT WELL.
•❑ Decommission ORIGINAL 1Y TALLATIONNotice Property Owner Name DREW DAVIES
of Intent Number Well Street Address 3682 HARSTINE ISLAND ROAD (VDT 2)
PROPOSED USE: Domestic 8 industrial ❑Municipal
QDeWater [j Irrigation Test Well Other 0 o City SHELTON Canty >wcasoN
TYPE OF WORK: Owner's norther of well(if none than one)LOT 2 Location SWI/4.1/4 1/4 Sec 25 TWfl 2t1 R 2 Rocli
to IlewwiJh 0Rardtoned Marhod:CIDug ❑Bored ❑ riven
()Deepened ®Rotary O morsel Lat/Long(s,t,r Let Deg Lat Min/Sec
DIMENSIONS: Diameter of well...6 inches,MOW 200 ft still REQUIRED ) Long Deg Long Min/Sec
Depth of a mpided well 200 R.
CONSTRUCTION DETAILS Tax Parcel No. 221252390012 (LOT
Caste( l Welded 6 Diem from+2 t.to 200 R.
Yutalled: Linerinstatled ' Diann Roar IL to R CONSTRUCTION ORDECOAArIISSIONPROCEDURE
®Threaded Diann from ft to ,R R.
Aldo atIots 117 u o Formation Deaeribe by color.draratler.sip of material and strurdne,and the bind and
Type of perforator usedsworeeel the n lesial in act stratum pmdrekd,with at heat one wiry for each change of
inthnration indicate all water encountered. (USE ADDITIONAL SHEETS IF HECLSSARY.)
SIZE of perk in by_II cad no.of pees ttcln t.to_It. MATERIAL FROM TO
Stress: Girl Yes dNo ViKPlc Location 189 SILTY BROWN TOPSOIL 0 2
Manufactures Name JOHNSON BROWN SILT HOUND SAND AND GRAVEL 2 35
Type 51,GTTED Model No. GRAY SILTY SAND AND GRAVEL 35 58
Dram 5 Slot size 010 ttom190 It to 195 R
Dean 2 Slat size 010 from 195 ft to 200 ft GRAY SILTY SAND AND GRAVEL 58 76
` CraraUFllterp idled:0 Yes 0 No ❑See of gravel/mild - GRAY STICKY CLAY • 76 1 t 8
Materials plated from R.to A GRAY SILTY SAND 118 165
Surface Seat:®Yes In No To abet depth?20 ft GRAY SILTY SAND,WET 165 180
Material used in seal$pWfY)NtTF.C'PIT S BROWN SAND AND WATER 180 200
Did any stress contain unuable voter? ❑Yes 10 No
Type of water'? Depth of nrata
Method of aging strata off
PUMP: Mmuemtref s Name
Type HP.
WATERLEVELS:Landihrfatx elevation above mean aealevel It
r
Natiolewd 34 R.lid owtupofwelt bate 2/3105
Artesian pressure the per square inch Date
Artesian van is cnnrolt ed by
(tap,valve,etc)
WELL TESTS:Newtown rammed ssterleveis'owned bdow dot clewd
Wass pump test node?DYe ®No If yes.bywhom?
Yield: gat.hsrn.with ttdrawdowoatter hrs.
Yield: *Ain.with ft stawdowo after ha
Yield stiffen.with _._.A dawdownafter Ms i
Amory dote gime*Om mz.m Wpm poop nrnad eV)Omer lawl atasmtradfvm rail
5 y tb wear level)
line Water Level Time Water Level Time Water Level
Date of test
Bailer test 20 galirrdn with R ft.drawdoam after 2 bal.
Airiest gal.hnin with dart set at t.der taw.
Marian Row gp.m Date
Temperature ofwater Kass chemical analysis made? ❑Yes ®No 1 _
Scat Date 2/2/05 Carpeted Date 2/3/05
t 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 end belief.
DriEa/EngineerTraineeName(Print) ED NELS N Dulling Company AP.CADIADRThLDqG INC
Driler/Engineer/1rainee Sigrattre C"-'-I /\j, Address PO BOX 1790
Driller or trainee License No. 1886 City.State,Zip SHELTON WA 98584
If TRAINEE, Contrada's
SakesLkerai Ns. Registration No.A.CADDI098R1 Date 2/7/05 •
Dri>er's Sirwtam Ecology is an 4=1 Opportunity Dreloyer. ECY 050-1.10(Rev 7103)
l'- f in a l i i� i '` k�=z,�n n ,t c u t a° t).t V 1;.. i•
Pfiniead from Meson County DMiR
•
Thurston County Environmental Health
n 2000 Lakeridge Dr.SW ®Olympia,WA 98502
OIL ®��. 16n R67_2611
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
f ~I OPM
Month Day Year —'—
Type of Water System(check only one box) ❑ Private Household
w �
0 Group A 0 Group B Other Z N
Group 8 Systems �ti
Group A and VIVU(J o -Provide from Water Facilities inventory(VYFI):
ID#
System Name:1k.5 -j 67
Contact SG
o ,.Person: ` r C t ten,af WM ..-K-A iA.ii VIA.A ecr r
Day Phone:('}1.)(�11- 3 S,.024 R. Cell Phone:( )
E-mail: pdV`s " ot(,�. Egane:(
Send results to:(Print full name,address and zip code or email address)
Sawn
t►�k.
SAMPLE INFORMATION
Sample collected by(name): )` u1/1 M\_ ,
Specific location or a dress ere sampleicoll cted Special instructions mments:
, Hr i �.
.56-Aiw thi 185EVf
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No f Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
XE.coil-GWR(PO')
❑Fecal-Surroce,use,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other /
S
4.0 Sample Collected for Information Only
Investigative_ Construction/Repairs Other--
LAB USE ONLY DRINKING WATER ER RESULTS S LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Ai Satisfactory
0 E.coli present ❑E.coli absent No Coliform detected
Replacement Sample Required:
0 Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1,
Fecal Coliform 1100ml Enteromrn ._l100 ml.
Method Code:[XSM 92238 ❑SM 9222D Date and Time Received: (615
❑SM 9215E� fJ ❑Enterolert® ,j"31 e.k^45
Date and Time Analyzed G, ' ' Dale Reported: �r,(./,,Z?—
Sample Number(DOH number plus five digits) Lab Use Only:
0 8 0
DOH Form#331-319(revised 01/16)
y
Thurston County Environmental Health
�,,; 2000 Lakeridge Dr. SW Olympia, WA 98502
-�jgrilipezr -� 360 867-2631
THURSTON COUNTYmonsionsamsnmei NITRATE TEST PANEL
Since 1852
Report of Analysis
Date Collected: (MM/DD/YY) D 5/ 3 L/ Z._z, ' System Group Type: (circle one) A B Other 2 igto,A
Water System ID Number: r k a "'•7 L. "—'7 . System?Name:- . 4 t.- -
Lab# Sample#: 080 —1.� _ County: MJ' j`''
Sample Locat'on: 3 „ill� r.5 i g tA.C. 1,5 Am) 4. Source Number(s): (list sources if blended or composited— ,
-A5k..l4-0,, ui i- ` 5g'f — , --' --
Sample Purpose.: (check anoronriate box) . Date Recei:per!• (M5-4!In/YY, C •i 7)Ci Z I ! -10
RC--Routine/Compliance(satisfies monitoring requirements) Date Analyzed:(MM/DD/YY) ! / 0 t / _
C—Confirmation(confirmation of chemical result)* ya_.---
Date Reported: (MM/DD/YY) C6 / C)r /
❑ I—Investigative(does not satisfy monitoring requirements) Sampler Comments:
❑ 0—Other(specify—does not satisfy monitoring requirements)
Sam le Composition: (check appropriate box) Sample Type: (check one) ❑ Pre treatment/Untreated(Raw)
S Single Source ❑ Post treatment(Finished)
B Blended(list sources in`Source Number(s)'field) ❑_Unknowns other t
f—1 c_ ('nennncifo( l:. wr a_la\ t� t 1
Sample Collected by:(„ame) CJV1}'t'
❑ D- Distribution sample Phone Number: 77 .? 3& oil-7
Send Repgrt to(mailing or e-mail address): Bile,o: 1(client name) ,
v . —1 w.l a , Jr A A le N n n c
ql..1%4.3.111-i I Vci liCi % a I ea"t t.....rl Iv It I. e.
6s,,k5 Dg, Titer,
EPA REGULATED AND STATE REGULATED OR REQUIRED
DOH ANALYTE DATA RESULTS UNITS MRL SDRL TRIGGER MCL EXCEEDS METHOD/
# QUALIFIER MCL? ANALYST
(X if yes) 0.1i..
0020 Nitrate-N O k 5 mg/L 0.5 0.5 5.0 10.0 = SM4500 NO3D/
E NITRATE LEVEL IN YOUR WATER SYSTEM IS:H :
Iti Compliance 10 mgiL is the maximum contaminant level allowed.
Out of Compliance
NOTES:
*Confirmation:include the original lab number,sample number,and collection date of original sample in either lab or sampler comments section.
DATA QUALIFIER: A symbol or letter to denote additional information about the result.
mg/L: milligrams per liter or parts per million.
MRL(Method Reporting Limit): The lowest quantifiable concentration of an analyte.
SDRL(State Detection Reporting Limit): The minimum reportable detection of ail analyte as established by the department.
TRIGGER: DOH drinking water response level. Systems with compounds detected at concentrations in excess of this level may be required to take additional samples or
monitor more frequently.
EXCEEDS MCL(maximum contaminant level): Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-291 WAC. Please contact the
department's drinking water regional office in your area to determine follow-up actions.
Lab Comments:
0—
i d' .