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HomeMy WebLinkAboutWEL2023-00002 - WEL Application, Design, Letter - 2/14/2023 a���`cVtct,, Date Received: '\ MASON COUNTY yH9 >) COMMUNITY SERVICES Amount Received: Rece ed —l' } SZS Building,Planning,Environm ental Health,Community Health (poop i y v 415 N.6th Street,(Bldg8 —Shelton,WA 98584 13 "r V ) WELD-0 o00 � Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT ^e�J�.� �t�I J �� PHONE 366 —ti ck) - c N 2.6 MAILING ADDRESS—STREET,CITY,STATE,ZIP PC 3c,c s i e\}- , c1 b5 b'i SITE ADDRESS—STREET,CITY,STATE,ZIP XXX b JA Svn I—:.kit 12,c-\ She1 , vn) PRIMARY PARCEL NUMBER(WELL SITE) ‘ 213-3 • l U 90012 SECONDARY PARCEL NUMBER(IF APPLICABLE) `� `` 32 +�13t4 W WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑ New 2rExisting l 'Wcll 0 Spring PROPOSED WATER SYSTEM NAME(REQUIRED) ZZ e l/e s 141 ►\ Well '7 PROJECT DESCRIPTION US'€ NYiS1-inq t,J 11 •}o pro`'ik a r for -two hkvrw, DIRECTIONS TO SITE/CONDITIONS J � _ '-}wy 3 fo Masorw L. }Zcc,ck. Avi(?rox I , 7 i»,I 1 -fig e.t: rocac)1 cux riy�•�- (Vie.+t c;rf,,.,,, '2(Do' clo:.w'r cc, )c\ o" Site Plan: (may also be attached) (property boundaries, structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) / z.S'cc ec—tom, S welt l //3'\''tJ't I 52 ir 0 WI FEB 1 4 2023 pr;MWV cv-c I By Submittals Checklist: (these additional items will be required for approval) 13 [ 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) g Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) t\1/p, ❑ 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 ❑ jgr ❑ 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 rorly.alei,County or State. What is distance to ROW? LO ❑ ❑ Does the ground slope away from thel water source site? (show slope on plot plan) Sia?E t`¢O A e4Wr h tds.E'ST, AT ibE Of lb 1t P C- ❑ ❑ Is the well cap satisfactory? El El Screened and vented? ,1 ❑ The well casing extends 7 abov evel ground:Pconcrete slab'? (circle one) ❑ ❑ Is there evidence of a surface seal? '❑ ❑ El Does the seal appear adequate? ❑ ,� ❑ Is a variance necessary for well site approval? Comments e,..c,vvt lke- irca.d, —�, A1JQ4'- VI�-RM /err SCrtfzcC� Wei cx 1.4)0-.), „,l ,, , 0.SELL.- -$Ab- corSFQ M M 1511`R. (c© 1ReC_o M rn exld 6e� c p I& -�q 5 - ofu� -� Mo a-nck. ck - £N(G`jF,u cL f-f Gr- a e-c-on& c o rx n e_c-± ern e-et• Pass ❑ Fail Inspector !„/I�l� G2 � � Date 2 Z`{ • Z Review Step 2: Two-Party Review: YES NO NA /NI ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test Driller GPM El ❑ Received Satisfactory Bacteriological Analysis? Date of test I 1 • S- Z Z Jal El ❑ Received Signed, Notarized, and Recorded Notice? AFN 2.) S El ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments oc14. es,ptbt uartc.S k?. 2 4A 3(ct - 2-3- a543 c>c>ct pproved ❑ Denied Reviewer �� Date 2L/ . Z3 Z' 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 l—SPECTRA Laboratories-Kitsap www.spectra-lab.cortt —WA ere esyer4ree natter, (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 11 / 3 I 22 Mason 3 55 ®KA lAcnL1 Dey Yeas — Type of Water System(check only one box) ❑Group A ❑Group B ❑Q Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# 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 rip ccde or a-mail) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name): Max Specific location where sample collected 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 unsat.routine) Chlorinated:Yes❑ No❑ ❑Distribution System Chlorine Residual:Total_Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample ISI I Unsatisfactory routine collect date: I I ❑ Chlorinated:Yes❑ No Triggered ❑ ❑Assessment Chlorine Residual:Total Free_ 4. Enumeraten Sarre Water Sample I S ❑E.col, ❑Fecal-surfam,GM,Spins:Flared Yes❑ No❑ 5.❑� Sample Collected for tnformaton Only. LAB USE ONLY DRINKING WATER RESULTS LA SE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑Ecoli absent Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E,coli /100m1. Fecal Coliforrn /100m1. FIPC 11 nil. Lab ID Number� O� r O Date and Time Received: (2. NOV 04Ion i n Method Code: Dale and Time Incubated: SM 9223 B NOV 0 4 2022 Date Analyzed: Dale Reported: DOH LatrSamplelt d W Lab Use Orly: 225 - DOH rum en31.313(elrx;sOu16)-Iryou nevi uv pwN tcn!n an aumat raw*ed1800 S5oin(roam Ca1711) Th'a and cller phi a5o.ro a:a?aSlt et vnrn.doh.wap ier'Wel/ratr 4-; I- O CL Ce al WATER WELL REPORT ` .. Original&1" copy-Ecology,2ndcopy-owner, 3i°copy-driller CURRENT F,t 0 1 0 L 1 Notice of Intent No.W E08306 H Construction/Decommission("x"in circle) D� 7-3 t []X Construction Unique Ecology Well ID Tag No. BAR602 41-' ❑ Decommission ORIGINAL INSTALLATION Water Right Permit No, EXEMPT WELL C Notice of Intent Number O Property Owner Name REEVES HILL LLC PROPOSED USE: E Domestic ❑ Industrial ['Municipal C ❑OeWater 0 lmgation ❑Test Well ❑Omer Well Street Address MASON LAKE DRIVE E. 0 TYPE OF WORK Owner's number of well(if more than one) - City SHELTON County MASON RI ❑x New well 0 Reconditioned Method: 0 Dug ['Bored ❑ Driven E 0 Deepened ❑Cable ['Rotary 0 Jetted Location SF. 1/4-1/4 NE 1/4 Sec 33 Twn21N R 3W EwM 0 Check DIMENSIONS:Diameter of well 6 inches drilled 100 R. Or One wDepth of completed well 99 ft. (s,t,r Still REQUIRED) wwm p C CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec Casing ID Welded 6 " Diam.from+1 ft.to 96 R. W Installed: 0 Liner installed " Dram.from ft.to ft. Long Deg Long Min/Sec is,, ❑Threaded " Diam.From ft to _ft. Tax Parcel No.(Required) 321331090012 a,,, Perforations: []Yes ❑x No CONSTRUCTION OR DECOMMISSION PROCEDURE O Type of perforator used Formation:Descnbe by color,character,size of material and structure,and the kind and .12 SIZE of perfs in.by in.and no.of perfs from R.to ft. nature of the material in each stratum penetrated,with at least one entry for each change _ of information. (USE ADDITIONAL SHEETS IF NECESSARY.) CU Screens: ❑Yes 0 No ❑K-Pac Location Manufacturer's Name MATERIAL FROM TO la Type Model No BROWN SILTY CLAY AND GRAVEL 0 5 CO•la Diam. • Slot size from R.to R MEDIUM TO LARGE GRAVEL WITH SANDY 5 Diam. Slot size Rom R.to ft. CLAY BINDER 13 O Gravel/Filter packed: ❑ Yes ❑x No Size of gravel/sand SMALL TO MEDIUM GRAVEL WITH BROWN 13 4.0 Materials placed from fl.to R. SILTY SAND 17 r Surface Seak EYes 0 No To what depth? 21 ft. BROWN SILTY CLAY,SOME GRAVEL 17 33 Material used in seal BENTONITE Cl LIPS GRAY SILTY CLAY WITH PEA-GRAVEL. 133 C MOIST I 41 CIS Did any strata contain unusable water? ❑Yes ❑x No L Type of water? Depth of strata MEDIUM TO LARGE GRAVEL WITH GRAY 41 ca SILTY CLAY BINDER,MOIST 52 Method of sealing strata off MEDIUM TO LARGE GRAVEL BROWN 52I PUMP Manufacturer's Name SAND,DRY I 55 l— Type: H.P. MEDIUM TO LARGE GRAVEL,BROWN 155 O WATER LEVELS:Land-surface elevation above mean sea level ft. SAND,WET 77 Static level 46 ft.below top of well Date 5/21/08 MEDIUM TO LARGE GRAVEL,COARSE 77 BROWN SAND,WATER 92 4.1 Artesian pressure lbs.per square inch Date O Artesian water is controlled by (cap,valve,etc.) BLACK COARSE SANDY GRAVEL,LOOSE, 92 12 WELL TESTS:Drawdown is amount water level is lowered below static level WATER I 100 Was a pump test made? ❑ Yes Qx No If yes,by whom? I CI) Yield: gal/min.with fl drawdown after hrs. O Yield: gal./min.with ft.drawdown after his O Yield: gal./min.with Rt.drawdown after hrs. R"',.tw i s-a• n mu O Recovery data(time taken as zero when pump turned off)(water level measured from well A c t_ o 1--1'4/ F- Li.i top to water levee O Time Water Level Time Water Level Time Water Level JUM 38 2(}J3 4-. d - WIS.IA gl.Ot'State E Dale Driest Department of Ecology L Bailer Test gal./min.with ft.drawdown after hrs. ' CS Atrrest 20 gal/min.with stein set at 80 ft.for 1 firs. UArtesian flow g.p.m. Date Q Temperature of water Was a chemical analysis made? ❑ Yes ❑x No Start Date 5/20/08 Completed Date 5/21/08 t W 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. ❑Driller❑Engineers Trainee Name )JOS1iU KOEPP Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature Address PO BOX 1790 Driller or trainee License No. 2874 City/State,Zip SHELTON , WA , 98584 IF TRAINEE:Driller's License No. Contractor's IDriller's Signature: Registration No. ARCADD1098K1 Date 5/21/08 ECY 050-1-20(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 110110 III III DII III II 1111111111111111111411111111111 Reeots I l L Lc:. Po 130 -7 I`I SkeI--oc 9)S-t1 Grantor(s): (1) Reeves ►7 I` LLC , (2) Grantee(s): (1) PUBLIC Legal Description (1) Pc 2 ofRL-A if 21 07 533 Tat 3 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 3 Z. I 3 3 - 1. 0 - 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 t 3 3 - 1 C0 - (1 O 0 2 Tax Parcel: (Connection 2) 3 2. ( 3 1 - 2 3 - 9 0 0 i 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: 12 e e V't u S 17 1 Welt 2 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 day of Ft'6Ain , 20 23 . Signatu •f G tor(s): (1) , (2) Page 1 of 2 STATE OF WASHINGTON ) ) ss. COUNTY OF MASON ) On this ,11, 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 , • and official seal the day and year last above written. 0':� Notary Pub ie in and for the State of . JOYCE BEVANS Washington, residing at OLD►- a_ NOTARY PUBLIC My Commission Expires: ( � 23 STATEOFWASHINGTON COMMISSION INAli3ER 43364 COMMISSION_EXPIRES MARCH 18,2023. STATE OF WASHINGTON ) • ) ss. COUNTY OF MASON ) On this IL1" 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 under m hand . d %fficial seal the day and year last above written. Notary Public i* "for the State of s. .pYCE M BEVANS Washington, siding at afryipe NOTARY PUBLIC My Commission Expires: ar t827 STATE OF WASHINGTON COMMISSION NUMBER 43364 COMMISSION EXPIRES MARCH 18,2023 SitammI-sifIeli-eaveii i '-Pagc 4