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HomeMy WebLinkAboutWEL2023-00003 - WEL Application, Design, Letter - 2/17/2023 ca MASON COUNTY3 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9679670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 03/22/2023 GREG TOMS 4366 HIGHLINE DR SE OLYMPIA, WA 98501 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL 2023-00003 180 W Killion Creek Rd 620122100020 The 2-party water system, Killion Creek Water System, 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.543 or email at jwilmoth@masoncountywa.gov Sincerely, Jeff Wilmoth EH Specialist Mason County Environmental Health Cate Received , MASON COUNTY , l 5 a( 'ii COMMUNITY SERVICES .: +szs r s, �jq. �� Building,Planning.Enmronmenta!Heal:h Ccmmumry Health 415 N.6"Street,(Bldg 8)-Shelton,WA 98584 WE L .ZO Z.3 • O O 6 63 Shelton. 360-427-9670 x400 Belfai;:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE ) 1I! Ia, Cek LL ) ] / kvis /frkwoo - __?be,- 7%P-/5 L' ) MAILINGADDRESS STREET, STATE, IP' f SO Gt1 k Jl'ob. Ce-eem kd 51-1p fft�% IdA 9 g5.84 SITE ADDRESS-STREET,CITY,STATE,ZIP .SA),A.e__ PRIMARY PARCEL NUMBER(WELL SITE) 'OZciZ —•Zi - 604026 1 SECONDARY PARCEL NUMBER(IF APPLICABLE) 6 ZO1Z -2 I - dv010 WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE ❑New Existing Well O Spring C.- l0 A-L PROPOSED WATER SYSTEM NAME(REQUIRED) _ K! ) ^(//o h C rP k Itf ev- J t�5 4,.- PRRn�OJECT DESCRIPTION qq ' I / tt� ),Ca iid� 'f Y�r r t ✓a�C Z�dc✓'7/j `✓e �� - ��t. &Je i /� S� eh t(/�4 v>;c,l 1 ! We 11 is ro p osef 1 0-6 t,I4 it)i-k'- —T Pare 'I c i / iar rJ-" 2 DIR.CTIONS TO SIT ONDITIeNS 41125 sG,a f7y, -,4f /,near ICU- -h, S l ia2_w. (11,112 k - )l r-rA_IN,t dS ki7/iok (7ree k k d( Y 101Liii '- Tajwt s- '' 5-.ca,s. to wQ // 5,Yr Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) r ,, .: „...]. 29 b to 9/\ Se fG 1/-Nky .. '- F, o- c�c� ij OI 1 Ni ` r Byl ~' a • & -• _/ � fIg20)2 Z ► - D''- -- �� N U i - & aee r • 1 y n t. ® well 5 lf� -3JO, , ( Submittals Checklist: (these additional items will be required for approval) Cy Satisfactory Bacteriological sample (this may be deterred if well is not yet drilled) (X Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) Septic Records (additional locating requirements may apply if there is a lack of septic records on file) Ibis 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 ource? If so is road private, County or State. What is distance to ROW? 29 k- , IU� ❑ ❑ ❑ Does the ground slope away from the water source site? (sh , slope on plot plan) ❑ ❑ ❑ Is the well cap satisfactory? ❑ ❑ ❑ Screened and vented? ?�e) ❑ J The well casing extends above level ground/concrete slab? (circle one) ❑ ❑ ❑ Is there evidence of a surface seal? ❑ ❑ ❑ Does the seal appear adequate? • ❑ ❑ ❑ Is a variance necessary for well site approval?Comments 41_ 2-3 t y 0 q ❑ Pass 0 Fail Inspector Date 3 ---20-- `2-3 Review Step 2: Two-Party Review: XNO NA ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test Driller GPM c ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test �4�t El Received Signed, Notarized, and Recorded Notice? AFN ( ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved 0 Denied Reviewer Atti W Date ?j _.), ___)3 Findings in this review reflect observed c nditions 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. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 2193934 MASON CO WA 02/17/2023 12:50 PM NOTCE I IIIIIII IIIIII III IIII I ISI lIIII lII IIII IIIII IIIII I I I I III 11111111IIII IIII Pages: 2 Return To DOM1a.5 Ovv,s. l $O Gts f<//(ri,h Cr e)<.&j s hd-hivt IATA CRAW MOM Grantor(s): (1) -Mr/4-ty. eflLtc. LL C , (2) NAM*31.18U4MATO* NOTO14042AW O 3TAT8 Grantee(s): (1) PUBLIC 23A1gX3 1#1OI8ZIMMO3 Legal Description (1) w (/ _ .5Pf_ NE- t1 SOS ,9r 3�tUt, (Abbreviated form: i.e. lot, block, plat or se` • ;to s'., Assessor's Tax Parcel: (1) 6 2. 0 I 2. - .2, 1 - d D f7 2 b 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) 2 D / 2 - 2, 1 - b D D .- O Tax Parcel: (Connection 2) 6 2 0 1 2 - Z 1 - 4 ® d ( 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: Ail/(oh ('►1e. k Wcz)-; s�'zw� 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 day of l 4-.1- is j , 20 2-3. Signature of Grantor(s): (1) ', , (2) Page 1 of 2 WATER WELL REPORT :a. d S'::_ DEPARTMENT OF Notice of Intent No, WE51436 ECOLOGY Unique Ecology Well ID Tag No. BNV822 Type of Work: TIMIPt State of Washington • Construction Site Well Name(if more than one well): O Decommission �'> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Greet Toms ❑Dewalering 0 Irrigation 0 Teat Well 0 Other Well Street Address 180 W Killion Creek Rd Construction Type: Method: El New well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 62012-21-00020 Dimensions: Diameter of boring 6 in,to 99 ft Was a variance approved for this well? 0 Yes Cl No Depth of completed well 99 ft. Construction Derails: wag I f yes,what was the variance for? Casing Liner Diameter From To 'thickness Steel PVC Welded Thread p I 0 6 in. 0 99 .025 in. © I 0 O I 0 Location(sec instructions on page 2) fa WWM or O EWM O I ❑ _in. in ❑ 1 ❑ O 1 ❑ SE '/.-%of the NW '/.;Section 12 Township 20N Range 6W O I _in. _ _ in. O I ❑ DID O I ❑ _in. _ in. O I ❑ ❑ 1 O Latitude(Example:47.12345) 47.239420 N Longitude(Example:-120.12345) -123.381202 W Perforations: 0 Yes Gil No Type of perforator used No.of perforations- Size of perforations_in.by in Drilkr's Log/Construction or Decommission Procedure Perforated from_ft.to_A.below ground surface Formation:Describe by color,character,sire of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes O No ❑K-Packer ,�•, Depth_li. information. Use additional sheets if necessary. Manufacturers Name Material From To Type Model No. Diameter_ Slot size_in.from _ft to ft. Brown fine sandy gravel,dry 0 4 Diameter Slot size_in.from ft.to--ft. Brown fine sandy gravel,siltbound,tight,dry 4 19 Sand(Filter pack:0 Yes O No Size of pack material IIIBrOWn fine to medium sandy gravel,tight,moist 19 25 Materials placed from ft.to fl. Brown clay,stiff,dry 25 36 19 ft. Gray clay,stiff,dry 36 39 Surface Seal: ]Yes ❑Nc To what depth? Brown clay,silty,tight,dry 39 46 1 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes El No Brown fine sandy gravel,tight,wet 46 49 _i Type of water Depth of strata Brown stiff clay,dry _ 49 58 i Brown fine sandy gravel,silty,tight,dry 58 83 Method of sealing strata off Brown coarse sandy gravel,tight,water 83 99 99 Pump: tvianufacturer's Name Type Brown siltbound gravel,dry H.P._ Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 402 fl. Siick•up of top of well casing 1 ft above ground surface Static water level 22 ft.below top of well casing Date 1/11/23 Artesian pressure lbs.per square inch Date _ Artesian water is controlled by (cap,valve,etc.) _ --. Well Tests: Was a pumping test performed? O No 0 Yes e0 by whom? Yield gpm with_ft.drawdown after hrs. Yield gpnl with ft.drawdown after-hrs. Yield gpm with ft.drawdown after hrs. _ _____ Recovery data(time-zero when pump is turned off--water level measured front well top to water level) Time Water level Time Water Level Time \Valer Level Dale of pumping test. - Hailer test gpm with_ft.drawdrwn after hrs.l Air test 30 gpm with stem set at 60 ft.for 1 hrs. J Date 1/11/23__ Artesnant flow-_gpm Temperature of water_.F Was a chemical analysis made? 0 Yes El No ( Start Date 1/11123 Completed Date 1/11/23 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 C Driller 0 Trainee 0 I'E-Print Name a ythian . Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 license No.2053 City,State,Zip Shelton,WA 98584 —u IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Dale 1/11/23 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. - E • TEit SA MANAGEMENT LABORATORIES tr+c. 1615 80th 8t E,Tacoma,WJA 98404 MOM NNW COLIFORM BACTERIA;ANALYSIS FORM bate Sample Collected Time Sample County Collected I i I2,3 1 :30r sPn ttorfi Day Year Type of Water System(check only one box) 0 Group A ❑Group B yLther Group A and Group B Systems—Provide from Water!Facllities Inventory(INFO: ID# / • System Name: VQ A\$ Contact Person: Al:QacliwAtilling; inc Day Phone:(3 es 426-3395 Cell Phone:( ) •Email: ,,,R a r Eve.Phone:( ) • Send results l'or. namrgedds s end zip cads) Ar.caa s nlri �, . ttc . 'Cl�t�ls�.einatl.-ec Shelton, 13A 98584— . • SAMPLE INFORMATION Sample collected by(name): Specific location where sample colle Special instructions or comments: QMV Sam ISo AI 1<;I1;en Lrref1S n Type.of$emiptel(selec(only,one typo ofspmpte'from types 1 through 5 below) 1.❑Routine Distribution Sample(AIP) 2.0 Repeat Sample(AIP) Chlorinated:Yes No (from distribution system after unset routine) Unsatisfactory routine lab number. Chorine Residual:Total_Free • 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S Chlorinated:Yes No ❑Triggered(AIP) Chlorine Residual:Total Free,__ ❑Assessment (ANP) . 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.col! ❑Fecal Flared Yes No • 5id\ Sample Collected for Information Only: FLAB USE ONLY DRINKING.WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.ccli present 0 E.coli absent. Bacterial Density Results:Total Coiifomt /100ml. Ecoli /100m1. Fecal Coliform /100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC 0 Sample too old 0 Sample Volume 0 Damaged Container 0 Datme Received: C lab Reference Number iu Receipt TempC°: Method o: Dale eported to DOH /) ) I Lab Use Only:AA°U 4R DOH LabSamplee 089 �'Z Dar Form 0331Jl9 i1 ctr9 9lrf•xym wed this p.Wi0m11an skeane seise ere e00.52u0127 ptGm'Ya rlty 330-9(0 , • It' s `�rre.,tS • � ,11 �. v'‘ !r ^.-�Jv+,` :jam. • 7 .,-. ,,-.. r_A, t•-• ,^ •,..\:';':.-A.. • Os Shoe °e �© ; n —4 1 Prop ea its 3 82 -Ha us-f CI- ` ' a 1efe, / IDrcDT 1 • PROVE ;JANI l02 iENVIRONMENTAL HEALTH \ lir .EBW i . , i 1,r#fik,1 h 1 ; Key; SG NUE' \" ^5O► Audio-Visual Alan* c 25 50 '15 GOB ii Cleanout RSbvl fi - 1200 Gallon Septic Tank ,�a t0`, ti v O 2-Compartment with J 3 i Effluent Filter • Pa1rcxl*tv2.0.2'2\ -O 00 2C o/ ) r 0 1000 Gallon Pump Chamber t80 Kikt iah Gres✓ - o.1 i A O Valve Control Box 44,-.4,b, .,:. V A Yf o i 1-f 5100349 '_vs PAULA JOY JOHNSON. % LICtNSi b t iegiGNE11.. , Exarfs o Tim - �`- • I 4 n