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HomeMy WebLinkAboutWEL2023-00003 - WEL Application, Design, Letter - 2/17/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT400 FAX:360-427-7787 03/22/2023 GREG TOMS 4366 HIGHLINE DR SE OLYMPIA, WA 98501 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00003 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 /S`7.7;;r y�L - �i- Late Received 1��.� MASON COUNTY _ a'- .�ri COMMUNITY SERVICES Ai R e , c/ ----- i S � Building,Plannmg.Environmental Health.Community Health 2. I 415 N.6ib Street,(Bldg 8)—Shelton,WA 98584 Y Y E L .X.O ,I) • 60 6 61 Shelton. 360-427-9670 x400 Belfair•360-275-4467 x400 Elma.360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANTICK ( /� I LLC /��J / PHO/NE/� y� �/ 41 MAILING r I I Q 3_STREET, k L LEC DO l - 6 Jams 1/ !f9//IHUY' 26(/— 79 v —/5 7 ISO t v k,/I/a1A Creek Qa( $liP1tt�tA // IdA 9 4 SITE ADDRESS-STREET,CITY,STATE,ZIP Sar,e PRIMARY PARCEL NUMBER(WELL SITE) 2o/2 — Z1 - Goo20 SECONDARY PARCEL NUMBER(IF APPLICABLE) 62_01Z -2,1 - 6vot0 WATER SOURCE SOURCE TYPE PARCEL LOT SIZE PARCEL 2 LOT SIZE El New L .Existing Well CI Spring 5 L 1 v PROPOSED WATER SYSTEM NAME(REQUIRED) K1^I✓[/ oh Cr?4 k. /JR1it55 d PROJECT DESCRIPTION /1 / f Af 1 r ce 1--/A 4 r p r I✓a4.e. .Z pd,✓'f� �/z/l S t,.vt. /.1J' . 1 r5 5� dkt A4 rr e 1 l/ Wen %S 1J'ry,p ose,v f -61,,% £ -0,- -rip Prtr-e ' t' ey JOtAl re� #Z OIRCCTIONS TO Srr&tONDITIONS __ 054 n r, St)a /-i-lit -/0e+I e._ -i4Ze4 -1"- 1l r.14,,2_,.., ere12 k• - )rrAAet, !X ki7/1a" Neck k at _ rP 11,E '' wts '' Si cal.5 to WI // s, � Site Plan: (may also be attached) (property boundaries,structures.well site w/100'radius,driveways.roads,septic/sewer components and lines,easements,etc...) 29,06 CD �r.l�i� � �" Se��c l�.�k5 D � � :-.-f' 60 S 'i fir' �t1 L r t4 : p Q �, Dru,� ►Q� FEES :t __. I N N� • , BY i .34 (, l a ' N ct y D O Well 5)+ i Submittals Checklist: (these additional items will be required for approval) pf Satisfactory Bacteriological sample (this may be deterred if well Is not yet drilled) , cif 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) 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 ❑ ❑ ❑ 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 road private, County or State. What is distance to ROW? 29 kt , vlWw ❑ ❑ ❑ Does the ground slope away from the water source site? (sh�w slope on plot plan) El 0 ❑ Is the well cap satisfactory? ❑ 0 0 Screened and vented? el ❑ The well casing extends tl) 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- Y j 3 i 1 O - — V1--3, -5 415 o ❑ Pass ❑ Fail Inspector its `,/V AN9C7---- Date 3 --22 `2-- Review Step 2: Two-Party Review: `t'V NO NA ❑ ❑ Water Well Report with adequate pump test on file? ?r9 , If NO,date of Capacity Test Driller GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments G� �y�z3 Approved ❑ Denied Reviewer ��� Date ?j 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', 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 11131 ill II IIII IIIIIII IIIIII IIII IIII IIIII IIIII lllllll III lllll IllI IlI Ill Pages: 2 Return To �OU�i a G- rr 1 �b (tif KJ(,iiv. Cr e)cckJ s Adhvi kkidA- ►�5.g1 ) r CRAW MAO'YNN Grantor(s): (1) 7<I(I ,Qr er.tik LL - , (2) MITOSI31.18114Y... t• ' • IH>'AW 3TAT$ Grantee(s): (1) PUBLIC 23fII9X3 I1OI22IMMO3 Legal Description (1) W '/ s /J E_ "1 r 3'#UL (Abbreviated form:i.e. lot, block, plat orse : • Assessor's Tax Parcel: (1) 6 2. C 1 2. - 'Z I - O 0 f7 2, 6 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) 6 Z 0 1 2. - 2, 1 - t7 D D 1- O Tax Parcel: (Connection 2) 6 2. 0 / z - 2 ( - O © d ( 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: k(l/(®h L'.r1e.e)& &Uctte ' ,5 ste.►� 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 g-f1, day of / 2i y,c.ah5 , 20 Z-. Signature of Grantor(s): (1) s . , (2) Page 1 of 2 WATER WELL REPORT7:va_ DEPARiMeNI 01 Notice ofIntent No WE51436 ECOLOGY Unique Ecology Well ID Tag No. BNV822 Type of work: State of Washington i7 Construction Site Well Name(if more than one well): 0 Decomnussimm r— Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Greg Toms 0 Dcwatorirug 0 Irrigation 0 Test Well 0 Other Well Street Address 180 W Killion Creek Rd Construction Type: Method: IN New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason U Deepening 0 Other 0 Dug ®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 1)No Depth ofcompleted well 99 fi. If yes,what was the variance for? Construction Details: trait Casing Liner Diameter From To Thickness Steel PVC Welded Thread p i 0 6 in. 0 99 .025 in. 13 I 0 O 1 0 Location(see instructions on page 2): C W WM or©EWM ❑ 1 0 _in. _ , in. ❑ I 0 0 1 U SE '.-%of the NW %,;Section 12 Township 20N Range 6W ❑ i p in. __in. ❑ I 0 0 I 0 O I in. in. ❑ 1 ❑ U 1 U Latitude(Example:47.12345) 47.239420 N _ _ longitude(Example.-120.12345) -123.381202 W Pet-foralions: ❑Yes (l 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,sire of material and structure,and the kind and Perforated from_ft.to_ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes O No 0 K-Packer Depth_ft. information Usc additional sheets if necessary. Manufacturer's 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,a. Brown fine sandy gravel,siltbound,tight,dry 4 19 Brown fine to medium sandy gravel,tight,moist 19 25 Sand/Filter pack:0 Yes 0No Size of pack material_in 25 36 Materials placed from It.to R. Brown clay,stiff,dry Gray clay,stiff,dry 36 39 Surface Seal: 1D Yes 0 Nc To what depth? 19 ft. Brown clay,silty,tight,dry _ 39 46_ Slatcrial aced in seal Bentonite Chips — Did any strata contain unusable wale?? 0 Yes El No Brown fine sandy gravel,tight,wet __-_— 46 — 49 Type of water? Depth of strata Brown stiff clay,dry 49 58 Method of sealing suata off Brown fine sandy gravel,silty,tight,dry 58 83 Brown coarse sandy gravel,tight,water 83 99 • Pump: Manufacturer's Name Tree Brown siltbound gravel,dry 99 D.P._ Pump intake depth:_ft. Designed flow rater ppn' Water Levels: Land-surface elevation above mean sea level 402 ft. Stick-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? gl No 0 Yes by whom? —_ Yield gpm with_ft drawdown after tits. Yield gpm with_ft.drawdown after_hrs. Yield gpm with_ft.drawdown after 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 I Date of pumping test — Bailer test—spin with : ft.drawikwir alter__hrs 1 _ Air test 30 gpm with stem set at 60 ft.for 1 hrs. r Date 1/11/23____ • Artesian flow_gpm Temperature of water_e F Was a chemical analysis made? ❑Yes r7 No I Start Date 1/11/23 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 CJ PE-Print Name ay ythian . -trilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 license No. 2053 __ _ City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No Contractor's • Sponsor's Signature Registration No.ARCADD1098K1 Date 1/11/23 ECY 050-1-20(Rev 09/18) lfyou need this document in an alternate format.please call the Winer Resources Program in 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can ca11877-833.6341. I • 'TER a MANAGEMENT LABORATORIES INC. . MINIM 1618 80th et E,Tacoma,WA 88404 MINIM - NNW COLIFORM BACTERI&ANALYSIS•FORM Date Sample Collected Time Sample County Collected Month Day Year Type of Water System(check only one box) e• 0 Group A 0 Group B Other Group A and Group B Systems-Provide from W Fadkties Inventory(WFI): ID# /� System Name: S • Contact Person':A,Cad . Nei. linq, Inc Day Phone:(36 • 426-3395 Cell Phone:( ) oe. ) Email: .."D�, Eve.Phone: Send results to: `n-,. .,..',91 and zip model t Arced i.Nel,.111iiiii. . ,..g.,. tAc!.?it-a...s.ep,„.,..cesoifs Sheltcn, �: 98584- SAMPLE INFORMATION Sample collected by(name): r Specific location where samplee con i Sp e ed: Special instructions or comments: :>-iQNV sea 1 0 !is K;i j,en L feer-j ti Type of Sa([pte;(seleat only one type gfsampte from types l:through:5 bblow) 1.❑Routine Distribution Sample(MP) 2.0 Repeat Sample(AIP) Chlorinated:Yes__No (from distribution system afterunset.routine) Unsatisfactory routine lab number. — I Chlorine Residual:Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: S ' l i-- ° Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total __Free_ ❑Assessment (AR) 4. Surface or GWI Raw Source Water Sample(Enumerafon) S l l ❑E.coil 0 Fecal Filtered Yes_Nu-.___ 5Sample Collected for Information Only: FLAB USE ONLY DRINK-INGAWATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Cofiform Present and Satisfactory ❑E.coli present ❑E.coli absent ���""" Bacterial Density Results:Total Col form J100m1. E.coli /100m1. Fecal Conform. _1100m1. HPC /1 ml. Replacement Sample Required: 0 TNTC ❑Sample too old • ❑ Sample Volume 0 Damaged Container 0 cal- woe Received: tt Lab Reference Number " ':_I.....•- ' 'old IN Recetpt Temp C°: Method o: I ii/Z 971 /1 Date Repot;tied to DOH I Lab Use Only:MOb dR /— I --d,;- (-el DOH Lab-Sampled • 089 6e 74 1 DOHFan9371319,.... Depl-tlyasreedcifpril ,nanaYeuflt.„„;®1..;s5..froorrrrmf7ttl. I 1 rs. 1,3 r n 'I -9 . 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