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HomeMy WebLinkAboutWEL2021-00041 - WEL Application, Design, Letter r ,,,c nG rz+i4yx y - cfiy MASON COUNTY t r Date Received: 1114 %� COMMUNITY SERVICES 4 ...m. Amq o Received • ` Building,Planning,Environmental Health,Community Health •kilt 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 Y Y E L '• 000)4 1 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE Ke1+4\ 1io1IItr 360 - 126 -U‘.16 MAILING ADDRESS-STREET,CITY,STATE,ZIP PO 4oy 7I1 5'elfoni WA 905961 SITE ADDRESS-STREET,CITY,STATE,ZIP XXX E LexinJ PItce Skel , W 11t 9a5$`1 PRIMARY PARCEL NUMBER(WELL SITE) ^ - N 00 I2 SECONDARY PARCEL NUMBER(IF APPLICABLE) {2.12s _7 71' 4100 21 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE flew 0 Existing WWe1l 0 Spring I.09 iAcres 1.46 acvrS PROPOSED WATER SYSTEM NAME(REQUIRED) Levin�1 Wok}- tve.11 PROJECT DESCRI Pro VIa+e (,va,}er 'o 1 'O reSih. ci.'1 S;Q,It eam'ity home b4tAny Si -es. •1 DIRECTIONS TO SITE/CONDITIONS f- 14W' 101 +6 Brock/ L*F4- on I�'IGK.�cftW . i-ef4" on Lexi11o,l �,S plact. T 4-tva (oh on WI driIlr �n ✓ prop-ellIinv. b Arca�c Ar► (tnl an 11 '23-Zo2v• Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius, driveways,roads,septic/sewer components and lines,easements,etc...) I 431 MI) L.474n5. \ 9luc� it.0A ; 41;,ta ik' t4' N Lo} z , _ C '& 1 1t ,n' _L°#1 St w_ ili uN 1 5 2021 144* Ito' By----lijil°"---- 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) otice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) LIB 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 -44 Review Step 1: Well Site Inspection: YES NO/I<IA ❑ [x ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) RK ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road pIiii County or State. What is distance to ROW? '-ID ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) "❑ ❑ Is the well cap satisfactory? �❑ ❑ Screened and vented? IIIThe well casing extends V abov el ground /c crete slab? (circle one) 2r ❑ ❑ Is there evidence of a surface seal? I2 ❑ ❑ Does the seal appear adequate? d K 5 O I g ❑ ❑ Is a variance necessary for well site approval? Comments 41 2 8 bSb _ 1.?-3. ►3 (..5 4 ass ❑ Fail Inspector ..---- Date (e I V5 )-) 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 I1 ❑ Received Satisfactory Bacteriological Analysis? Date of test I?I I 7d t ❑ Received Signed, Notarized, and Recorded Notice? AFN 7-I �j� / �}/S�/�. L� LJ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments proved El Denied Reviewer ` Date SI5h4::'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`h, 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 r ^.u�gQ 0_ %'o cA p „ 01(3X -9f t sue, 9 fb tn� N % G my �y45 ,ay n D I' . 1 ' A' e 3 / 3 9-9 s 0 Z —' 1 !; • g1-1 1 gip _ k ...y.7545', 7 ' Ii A V \ I 1 1 9 I L \ _ y _ \I1 I3,1_... V 1 / - (tr` 6---- i0 1 w gI''4 _`� 1 Printed From Mason County DMS Printed from Mason County DMS .0- , c-vi-cis.-,. , o,, • (-,) " k " I ..,.) \, -,.:, ,,,,,„,,, i t-r -. h =/ i; (Y b 11 ''j ' - -., 1 i rz'L 1 -1 - I .,_'. -61 fioi.1 H I .• r, ' 1 c , , 1 I / , . --0 k Q - ../ ,- • ......,) \ ' . ....„., I.. 13 I •, I ••4 I 4 .."I , . 1 i 1 srirrt, ., :gi'\5‘c I)( I —6' i 0 1.7 ... I 1 i kt I i tz .-- , %. 4,..,_i,„ \,,,._ %. rc4-\ --- ' -.,,.__ I. N cZ ., N , \ ( i :.-.--, --------r- \ N • 4 N .0, / - • A ),..... -111 o g -1 0 P -1 .c.--- .0, ,,,,,,.., i ,, 0\ ._._. co• 0--- -• • ..--_ ,,) 1 o 1 Y i r- x; ',-7, ,,, ., ek,. ri . • . . , 0,-1---q 1 7 S -4-0,-- ' , A• -- • . , '1 ...._ 6-- .6--- e 3 9-9 Printed From Mason :,'' ounty DMS Printed from Mason County DMS ...,.. ' WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE41469 ECOLOGY Unique Ecology Well ID Tag No. BMS018 Type of Work: Wk state of Washington Site Well Name(if more than one well): El Construction ❑ Decommission i ' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Keith Fuller ❑Dewatering 0 Irrigation CI Test Well 0 Other Well Street Address E Lexington Place Construction Type: Method: City Shelton County Mason lEI New well 0 Alteration 0 Driven ❑Jetted 0 Cable Tool El Deepening ❑Other Dug ©Air- CIMud-Rotary Tax Parcel No. 42125-77-90012 Dimensions: Diameter of boring 6 in.,to 160 R. Was a variance approved for this well? ❑Yes O No Depth of completed well 159 R. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I ❑ 6 in. a 156 .025 in. 1 ❑ O I ❑ Location(see instructions on page 2): ©WWM or 0 EWM ❑ I ❑ in. — in. ❑ I ❑ 0 I ❑ SE y,-'/,of the NW 'A;Section 25 Township 21N Range 4W ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑❑ I ❑ in. in. ❑ I ❑ 0 I 0 Latitude(Example:47.12345) 47.2835801 Longitude(Example:-120.12345) -123.1364911 Perforations: ❑Yes ©No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations Size of perforations in.by in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft.to R.below ground surface name of the material in each layer penetrated,with at least one entry for each change of Screens: Bill Yes ❑No Ii]K-Packer b Depth 153 ft. information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Wire Wrapped Model No. Brown sandy gravel,tight,dry 0 3 Diameter 5„ Slot size.030 in.from 154 ft.to 159 ft. Diameter Slot size_in.from ft.to ft. Black fine sandy gravel,gray siltbound, 3 cemented dry 9 Sand/Filter pack:❑Yes 0 No Size of pack material in. Brown fine sandy gravel,siltbound,tight,dry 9 92 Materials placed from ft.to R. Chocolate peat binding brown gravel,tight,dry 92 94 Surface Seal: El Yes ❑No To what depth? 19 ft. Multicolored medium sandy gravel,tight 94 121 Material used in seal Bentonite Chips Brown gravelly medium sand,tight,moist 121 134 Did any strata contain unusable water? 0 Yes KI No Type of water? Depth of strata Brown medium to coarse sandy gravel,water 134 Method of sealing strata off bearing 141 Brown fine sandy clay,tight 141 147 Pump: Manufacturer's Name Type: Brown medium sandy gravel,loose,water 147 160 li.P._ Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 321 ft. Stick-up of top of well casing 1.5 ft.above ground surface Static water level 123 ft.below top of well casing Date 11/23/20 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No ❑Yes c' by whom? Yield_gpm with_ft.drawdown after_hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown alter 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_gpm with_ft.drawdown after hrs. Air test 30 gptn with stem set at 150 ft.for 1 hrs. — Date 11/23/20 Artesian flow gpm _ Temperature of water 51 °F Was a chemical analysis made? ❑Yes J No Start Date 11/20/2020 Completed Date 11/23/2020 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. O Driller❑Trainee Pr' a Roger Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No, 205 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 11/24/2020 • ECY 050-1-20(Rev 09/18) 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. 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com ...Where experience terra., (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 11 I 30 I 20 11 30 Om Mason Month Day Year I -.--- PM t Type of Water System(check only one box) ❑Group A ❑Group B 0Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Keith Fuller-E Lexington PI,Shelton Contact Person:Arleta Eisele/Arcadia Drilling Day Phone: 360-426-3395 Cell Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send results to:(Print full name,address and zip code or e-mail) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name): Max Specific location where sample collected: I Special instructions or comments: Well Head BMS018 Type of Sample(check only one box) 1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ ❑Distribution System Chlorine Residual:Total_Free_ Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample —— S I I I Unsatisfactory routine collect date: l 1 ❑Triggered Chlorinated:Yes ElNo❑ ❑Assessment Chlorine Residual:Total Free_ 4. Enumeration Source Water Sample S ❑E.coil ❑Fecal-Surface,GWl,Springs:Filtered Yes El No El 5. Sample Collected for Information Only:Investigative LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and KSatisfactory ❑E.coli present ❑E.coli absent I Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform /100m1. HPC /1 ml. Lab ID Number Da®Eitirnefected2020 1`0 Method Code: Date3r jj ne I(ube(ed:2020 SM 9223 B q Ut` U 1 Date Analyzed:DEC 0 2 2020 DateReportedDEC 0 2 2020 DOH Lab-Sam # Lab Use Only: {• L 225 . 6 L b .L DOH Fenn#331-319 tefleole 0441-If you need Hs natation In en llorn ve kneel,fall 800.525 0127(7DmTP cell 711). Thin end dhr publbaeenl ara avalee at ewe.doh ea.govldinhinpxda, 2159162 Mason County WA 06/11/2021 11:51:15 AM NOTCE eRecorded #158757 RecFee: $104.50 Pages: 2 FULLER Return To:k O rzi1_A Mk Kahl ally Po Pc -PI S h,ef lve1 i W Q %S '1 0 NOTICE TO FUTURE PROPERTY OWNER F PRI TE TWO-PARTY WATER SYSTEM I(We)the undersigned gantor(s),certify that the wa mated on parcel situated in Mason County, State of Washington,herein described, SP.tr 2.6610 13 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of� 1 , -- 7 i -- R 8 0 1 '. Has been designated 10 serve a so • a • o the following parcels situated in Mason County,State of Washington;herein descri d: (• fated legal descrtptfora(.s}and tax parcel number(s)affected) SP#2652 A- OR Subdivision islon v Lot Range Township Section And having the Ta Pa c Num of:H _( 2 $ ---7.7 --.1_-4-.0 2 } OR Subdivisio vision Lot Range Township Section And hay' the arcel Number of: -- -- The sy. ner Is responsible for keeping this system in compliance. . - a i system is: 1.0eyir1�7'4R Win+ his syste is designed to provide for two service connections.Planning and design approvals must be 6•• .fined ' .ni the department prior to expanding beyond this number of services.Additionally,a water , e* ained from the Department of Ecolo ,is required if the water system exceeds exemption t rds. This system(has/has not)be n ,,•a 4,s one ore waivers from specific provisions of the guiations. e=-- J Signature of Orantor(s): .. ,� Printed name of Grantor(s): ke"i4. Tul 1t't( , 14drt,it slit LAND TITLE COMPANY Grantee: Public has paced this document of record as a customer courtew and accepts no&iebUity for the accuracy or validity of Page I of 2 the docurnont. ,„, ,_.- , State of Washington County of Mason ) I,the undersigned,a Notary Public in and fox tl e na • County and State,do hereby certify that on this OA day of jUI' .. ,20 personally appeared before me,who is known to b zgner of the above instz•uwnent,and acknowledged that he(she)Qsignsd it. Given,under my hand and official 1 the day and year Task above writte Notary Public in and for the State of Washington, Residing at ( a My commission expires; 6" 23 JOYCE M BEVANS NOTARY PUBUC STATE OF WASHINGTON COMMON',AMBER 433" COMMISSION WIRES PARCH*2023 Page 2 of 2 2159162 Page 2 of 2 06/11/2021 11:51:15 AM Mason County, WA r 2159161 Mason County WA 0611112021 11:51:15 AM AGREE eRecorded #158757 RecFee: $105.50 Pages: 3 Return Address: FULLER Keith Fuller PO BOX 714 Shelton, WA 98584 O 0 SHARED 2 PART LL AGREEMENT GRANTOR: Keith D Fuller and Kathryn R Fuller GRANTEES: Keith D Fulle Kat n R Fuller LEGAL DESCRIPTION bre ' : portion of the Northwest quarter of Section 25, Township 21 North,Ran .M., in Mason County, Washington. ASSESSOR'S PAR N .: 42125-77-90012, 42125-77-90021 This agreement ' ade i ''day of June 2021,by the grantors Keith D Fuller and Kathryn R Fulle , Husb and wife, who are the owners in fee simple of the following described r t ason County, Washington. 1 Sh Plat No. 2640, recorded October 23, 1995,under Auditor's File o . 5958 and 615959, being a portion of the Northwest quarter of Section 25, T s 21 North, Range 4 West, W.M., in Mason County, Washington. 0 of 2A of Short Nat No. 2652, recorded October 25, 1995,under Auditor's File Nos. 616097 and 616098, being a portion of the Northwest quarter in Section 25, Township 21 North, Range 4 West, W.M., in Mason County, Washington. Parcel Nos. 42125-77-90012, 42125-77-90021 hereafter Lot lB of Short Plat No. 2640 and Lot 2A of Short Plat No. 2652, respectively. LAND TITLE COMPANY has placed this document of record as a customer courtesy and accepts no liability for the accuracy or validity of the document. Shared 2 Party Well Agreement- Location of the Two Party Water System There is a two party well and water system(herein referred to the Water System)on Lot 1B of Short Plat No. 2640 which serves Lot 1B of Short Plat 2640 and Lot 2A of Short Plat No.2652. Connection of Power to Water System O Connection of electrical power to the water sys Slnk b- . e responsibility of the first fiowner to connect to the water system.The o that fi .t connects power to the water system shall be referred to below as the Fi - second owner to connect the water system shall be known as the Seco Own . Cost of Operation,Maintenance and Regal ter System The Second Owner will pay the First Owner$10.00 each month to compensate for electricity provided to the wat stem. The owners of Lot 1B of Short Plat No. 2640 and Lot 2A of Short Plat No. 2652 equally in all other costs of operation, maintenance,and repair o viii.,- , water system.The cost of repairing common distributions lines shal be b equally by all owners. Each owner shall be responsible for the maintenance,repair, • ilacement of any water lines supplying water from the well and water system h o 4*s own particular dwelling and/or property. Easement for 1 ' e ater lines The gran • ' h. -b tablish an easement for well and waterline on Lot 1B of Short Plat No. 26 I. ► -tinning at the Northeast corner of Lot 1B of Short Plat No.2640;thence runn' Sul- ong the Easterly line of Lot 1B of Short plat No. 2640 a distance of 80 feet to t t of beginning of said easement.Thence along the center line of said easement e . ° 32' 10"West a distance of 10 feet to the terminus of said easement,together with rM er side of said center line. uccessors and Assi.ns s agreement shall run with the land and shall be binding on all parties having acquired any right,title or interest in the land described herein or any part thereof,and shall pass to and be for the benefit of each owner thereof. Enforcement of the Agreement Parties not conforming with the provisions of this Agreement shall be subject to interest charges of 12%per annum together with all collection fees. Unpaid charges shall become a lien against the property owned by the non-conforming party and a Notice of Claim of Lien may be filed with the Mason County Auditor.The owner of any Parcel liened shall also be responsible for costs and attorney's fees associated with filing and collection of the lien Shared 2 Party Well Agreement- 2159161 Page 2 of 3 06/11/2021 11:51:15 AM Mason County, WA r Amendment This agreement may be amended by written instrument agreed and signed by all of the owners of Lot 1 B of Short Plat No.2640 and Lot 2A of o. 2652. O Dated: Junes ID ,2021. 0 )Li \cLO :-T ,,,,„„„e,,,,,Lt Keith D Fuller Kathryn R Fulle STATE OF WASHINGTON ss. COUNTY OF MASON D ) I, the undersignez oT�, C blic in and for the State of Washington, do hereby certify that on this 1,610 ay of♦i�. - , 2021 personally appeared before me Keith D Fuller and •thy+• R Fffler to me known to be the individual described in and who executed t rurnent, and acknowledged that she signed the same as her free and vol ct'T' ry q, deed,for the uses and purposes therein mentioned. GIV O n y handy fficial seal the day and year last above written. C ''/ t •nd for the State of WA JOYCE M SWANS ngton,residing at Olympia.- NOTARY PUBLIC y Commission Expires: 6 -I$?j STATE OF WAS IBER NG TON COMMISIIIQtleriFIE$MARCH 112023 Shared 2 Party Well Agreement- 2159161 Page 3 of 3 06/11/2021 11:51:15 AM Mason County, WA