HomeMy WebLinkAboutWEL2023-00002 - WEL Application, Design, Letter - 2/14/2023 OJv� C
/ � MASON COUNTY Date Received i 4 ...2..-2,
t "' . COMMUNITY SERVICES
�-_ <I Amount Received: Rece
.y, SAS .:
yet, ,r Building,Planning,Environmental Health,Community Health tr
415 N.6`"Street,(Bldg 8)-Shelton,WA 98584 W E L 3 -- 0 OOp
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
., ........... -
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT n
eJ� LLC
t I J PHONE 366 --9 1 0 ^ CS q 2 6
MAILING ADDRESS-STREET,CITY,STATE,ZIP
Pc 3 .7
Cx 14 S‘,e\}-at, A A %ioS1
SITE ADDRESS-STREET,CITY,STATE,ZIP
KM( E , / doe‘ L„k.t. 12 e c.\ Sher , kJ) 4 %S b L1
PRIMARY PARCEL NUMBER(WELL SITE)
32 I33 • 1 o-• 90012
SECONDARY PARCEL NUMBER(IF APPLICABLE)
_32 134 -2 3 (ico le
WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE
❑ New )Existing ®'Well ❑ Spring 3 , p'3 cat:nes 5 • U 1 04.01e.S
PROPOSED WATER SYSTEM NAME(REQUIRED)
QV e\Pej 141 ►1 Well 'I
PROJECT DESCRIPTION i, ]
USe_ e iS T1 nq O.)v I1 to pa)v141e. )aIv/ for o 1nt4le 11\/ I -1.
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DIRECTIONS TO SITE/CONDITIONS
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Wv-tl Is c02P1-1,Y 2ot.' Jo,A," (-0oa 0.A 1F4-.
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)
N Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
fil Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
gd Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
N/a ❑ 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
❑ j1 ❑ 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 roariv `County or State.
What is distance to ROW? tf0
❑ r ❑ Does the ground slope away from the water source site? (show slope on plot plan) Si.O t V -)J eP.'M
EA�i rtc 0.E9T, AT it Cf to w;is
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented?•
,I
❑ The well casing extends 17 abovelevel ground/toncrete slab? (circle one)
J ❑ ❑ Is there evidence of a surface seal?
71 ❑ ❑ Does the seal appear adequate?
❑ 0 ❑ Is a variance necessary for well site approval?
Comments
Ai. e�t� ��?s-R.IYI ccLJ/crf Suf,fttC¢— Wct)(14.4_"
ckwc•-� -6-srvt ' .,1 1.1e�4 ►SELL -1A6- BAR t e
tZer_o r►t m es11,� 6ec� s,c ( l t,�-ek 4 fz 5u �— ` I re, ,�A a-n- nn owe pl
t re.` C�wt� Ge-t-tLr- e-rx C Grlrle_(?± cis4c1e'GL
Pass ❑ Fail Inspector j /t � `1 Date `.'. Z `( - Z
Review Step 2: Two-Party Review:
YES NO NA
z ❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test l 1 • . - Z Z
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZI 3 11 S
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments tra L c)c,RD( .tom-rLS 't?- 2-40 3 Kt t 2_3 • 054i a›o9
J pproved El Denied Reviewer //1t'u, J ,mac Date 1. - 13
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
1786 SE Mile Hill Drive
Port Orchard,WA 98366
J SPECTRA Laboratories-Kitsap www.spectra-lab.com
...WArro erpnLerr enamor (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
11 / 3 / 22 ANMason
3 . PM
Mont Day Year
Type of Water System(check only one box)
0 Group A 0 Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IDft
System Name: Island West Associates
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 cede or e-mail)
arleta@arcadladrilling.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Max
Specific location where sample coileded: Special instructions or comments:
Well Head#BAR602
Mason Lake Road,Shelton
Type of Sample(check only one box)
1.❑Routine Distribution Sample 2.Repeat Sample(after onset.routine)
Chlorinated:Yes❑ No❑ ❑Distribution System
Chlorine Residual:Total_Free_ Unsatisfactory routine lab number:
3.Source Ground Water Rule Sample
l S I I I Unsatisfactory routine collect date:
❑Triggered Chlorinated:Yes❑ No El
❑Assessment Chlorine Residual:Total Free
4. Enumeration Some Water Sample
❑ S
E.coil ['Fecal-se....,cwl,springs:Flker d Yes❑ Na❑
5.El Sample Collec'ed for InformaSon Only.
LAB USE ONLY DRINKING WATER RESULTS LA SE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent
Replacement Sample Required:
0 Sample too old(>30 hours) ❑INTC ❑
Bacterial Density Results:Total Coiiform 1100m1. E.coli /100m1.
Fecal Coliform /100m1. HPC /1 ml.
Lab ID Number Date and Time Received'
02 .O 022 r1533 --
Method Code: Date and Time Incubated:
SM 9223 B NOV 0 4 2022
Date Analyzed: Date Reported:
Nnv 51117, -- NOV 5'
DOH LabSample# Lab Use Only:
225 - j d 2.0
DOH Fpm S531.319(el'ectm 04/161-Ir you nad 0r7 ` final Marna,o ra¢el ail e03 WS 007 krDOCi YLHTh3
1h'1 end 0.1er p'+Ncefonr oa 6,?ei1 el eww.dchwa0addistingoele.
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WATER WELL REPORT
..!t Original&1" copy-Ecology,2ndcopy-owner. 3'copy-driller CURRENT
h t i I OCI Notice of Intent No.W E08306
H Construction/Decommission("x"in circle) 3O�7-3
S E Construction Unique Ecology Well ID Tag No. BAR602
4' ❑ Decommission ORIGINAL INSTALLATION Water Right Permit No. EXEMPT WELL
t` Notice of Intent Number
PROPOSED USE: ❑x Domestic ❑ Industrial ❑Munici Property Owner Name REEVES HILL LLC
0 ❑Dewater ❑Imgation ❑Test Well ❑other Well Street Address MASON LAKE DRIVE E.
TYPE OF WORK:Owner's number of well(if more titan one) City SHEI.TON County MASON
va ❑x New well 0 Reconditioned Method: 0 Dug ❑Bored ❑ Driven
E 0 Deepened 0 Cable ['Rotary 0 Jetted Location SF. 1/4-I/4 NE 1/4 Sec 33 Twn21N R 3W EWA ❑ Check
DIMENSIONS:Diameter of well 6 inches,drilled 100 ft. (S,t,r Still REQUIRED) wOr One
0 Depth of completed well 99 ft.
C CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec
Casing ['Welded 6 " Diam.from+1 ft.to 96 R.
U Installed: 0 Liner installed " Diam.from ft.to ft. Long Deg Long Min/Sec
4=,, ['Threaded " Diam.From ft to ft. Tax Parcel No.(Required) 321331090012
Perforations: 0 Yes ❑it No CONSTRUCTION OR DECOMMISSIOP(PROCEDURE
O Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and
.12 SIZE of perfs in.by in.and no.of perfs from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change
L. of information. (USE ADDITIONAL SHEETS IF NECESSARY.)
CU Screens: ❑Yes (><]No ❑K-Pac Location '
Manufacturer's Name MATERIAL FROM TO
Type Model No BROWN SILTY CLAY AND GRAVEL 0 5
iwtCO Diann. . Slot size from ft.to R MEDIUM TO LARGE GRAVEL WITH SANDY 5
CI Diem. Slot size from ft.to R.
CLAY BINDER I 13
SMALL TO MEDIUM GRAVEL WITH BROWN 13
(I) Gratrel/FRterpacked: ❑ Yes ID No Size ofgraveVsand 17
.wC 1wa Materials placed from It to ft. SILTY SAND
4 Surface Salk 0 Yes 0 No To what depth? 21 ft.
BROWN SILTY CLAY,SOME GRAVEL 117 33
C Material used in seal BENTONITE CHIPS GRAY SILTY CLAY WITH PEA GRAVEL, 33
C MOIST 41
t4 Did any strata contain unusable water? ❑Yes Q No
MEDIUM TO LARGE GRAVEL WITH GRAY 41
L. Type of water? Depth of strata SILTY CLAY BINDER,MOIST 52
Method of sealing strata off MEDIUM TO LARGE GRAVEL,BROWN 52
PUMP Manufacturer's Name SAND,DRY I 55
F' Type: H.P. MEDIUM TO LARGE GRAVEL,BROWN (55
0 WATER LEVELS:Land-surface elevation above mean sea level R. SAND,WET I 77
Static level 46 ft.below top of well Date 5/21/08 MEDIUM TO LARGE GRAVEL,COARSE I77
d BROWN SAND,WATER 92
Artesian pressure lbs.per square inch Date
Q Artesian water is controlled by (cap,valve,etc) BLACK COARSE.SANDY GRAVEL,LOOSE, 92
WELL TESTS:Drawdown is amount water level is lowered below static level WATER I 100
Was a pump test made? ❑ Yes []x No If yes,by when?
CD Yield: gal./min.with ft drawdown after hrs.
G Yield: gal./min.with ft.drawdown after _hrs -
O Yield: gal./min.with ft.drawdown after hrs. few a�-a a e
✓ Recovery data(time taken as zero when pump turned off)(water level measured from well C t. . 11-1 1/ F—L)
Li.i top to water level)
oiii Time Water Level Time Water Level Time water Level
JUM 3 0 2008
d - Wasiijiigtuit.,)hale •
E Date of test Departmbnt of Ecology
L Bailer Test gal./min.with ft.drawdown after hrs. I
eaAiriest 20 gal/min.with stem set at 80 ft.for 1 hrs.
w Artesian flow g.p.m. Date
Q Temperature of water Was a chemical analysis made? ❑ Yes ['No Start Date 5/20/08 Completed Date 5/21/08
0
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 an the information reported above are true to my best knowledge and belief.
❑Dril led:Engineer IDTrainee Name ) K JOST EPP Drilling Company ARCADIA DRILLING INC.
Driller/Engineer/Trainee Signature Address PO BOX 1790
Driller or trainee License No. 2874
City,Statc,Zip SHELTON • , WA , 98584
IF TRAINEE:Driller's License No.
Contractor's
I Driller's Signature: Registration No. ARCADD1098K1 [Pate 5/21/08
ECY 050-t-20(Rev 4/07) Ecology is an Equal Opportunity Employer
•/
2193775 MASON CO WA
02/14/2023 12:03 PM NOTCE
REEVES HILL LLC #184262 Rec Fee: $204.50 Pages: 2
Return To �IIIIII�0111011��11111 I IIIIII 111 IIII 1011 101111111I 111 D II)11�� 11
f2eev`...S N I 1 L Lc
Po Boy 71'
Skelton , 1AJ1 64)5-81
Grantor(s): (1) R'eeVeS ►1 I` LLC , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) PCL 2 ct AAA S 33 T2i 3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 Z t 33 10 9 0 0 1 2
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) 3 2 1 3 3 - 1 0 - a 0 0 1 2
Tax Parcel: (Connection 2) 3 2 l 3 H - Z 3 - 9 D o t O
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Reevts 11 Well 1
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 1 >r" day of FE 6040cy , 20 23 .
Signatul f G tor(ss):�
(1) ✓ --t-- , (2)
Page 1 of 2
tiii-nci-v,ywri-- •b Tu.1rr_ A.\ s,�
STATE OF WASHINGTON )
) ss.
COUNTY'IO`OF MASON )
On this t`I'� day of February, 2023, before me, the undersigned, a Notary Public in
and for the State of Washington, duly commissioned and sworn, personally appeared
Keith Fuller to me known to be the Managing partner of Reeves Hill, LLC, the limited
liability company that executed the foregoing instrument, and acknowledged the said
instrument to be the free and voluntary act and deed of said limited liability company, for
the uses and purposes therein mentioned, and on oath stated that he is authorized to
execute the said instrument.
GIVEN under , a and official seal the day and year last above written.
41.0;� ___
Notary Pu.,,��,I nd for the State of
Washington,residing at Ql JOYCE- BEVANS
My Commission Expires: NOTARY PUBLIC
U� 2-3 STATEOF WASHINGTON
COMMISSION NUMBER 43364
COMMISSION EXPIRES MARCH 18.2023
STATE OF WASHINGTON )
) ss.
COUNTY OF MASON )
On this l day of February, 2023, before me, the undersigned, a Notary Public in
and for the State of Washington, duly commissioned and sworn, personally appeared
Keith D. Fuller and Daniel F. Holman, to me known to be the Managing Partners of
Island West Associates, the partnership that executed the foregoing instrument, and
acknowledged the said instrument to be the free and voluntary act and deed of said
partnership, for the uses and purposes therein mentioned, and on oath stated that they are
authorized to execute the said instrument.
GIVEN un.- m hand . d ,.fficial seal the day and year last above written.
r -
Notary Public e State of g�ANS
Washington, —Idmg at .10YCE M
NOTARY PUBLIC
My Commission Expires: 1827
STATE OF WASHINGTON
s, COMMISSION NUMBER 43364
;COMMISSION EXPIRES MARCH 18,2023