HomeMy WebLinkAboutWEL2023-00001 - WEL Application, Design, Letter - 1/3/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670, EXT 400
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BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA: 360 482-5269,EXT 400
FAX:360-427-7787
PHINNEY MORIE L CHURCHMAN
9683 CLIPPER PL NW
SILVERDALE, WA 98383
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00001
132 NE TIGER LAKE RD WEST
123052100101
The 2-party water system, Churchman 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 x581 or email at
rhompson@masoncountywa.gov
Sincerely,
Rhonda Thompson
Environmental Health Specialist
Mason County Environmental Health
0.c
MASON COUNTY Date Received
�'v1111" I COMMUNITY SERVICES Amon Receve •
Building,Planning,Environmental Health Community Health
.5
415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 WE L a -- a o d0 1
Shelton 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
,44o(l 1-V 0 PF/) NN E/ 3 0- Z-7I - yz7 '
MAILING ADDRESS-STREET,CITY,STATE,ZIP
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SITE ADDRESS-STREET,CITY,STATE,ZIP
13 2— N E- -n C� -e- 1-4- e ►2-b tU
PRIMARY PARCEL NUMBER(WELL SITE)
t Z3OS —"ZI-e?I0 I
SECONDARY PARCEL NUMBER(IF APPLICABLE)
t230.�_ —Zl — 00/ 0Z
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
\ew 0 Existing Well 0 Spring
PROPOSED WATER SYSTEM NAME(REQUIRED)
C 1 u 1-f v 1114 NI 04- 'z-- SY STEM
PROJECT DESCRIPTION ('�
710a / i1'2 JtL-L
DIRECTIONS TO SITE/CONDITIONS ///
OFF O F ' e j 4 67 E7L L- CE Q l' (A.J 5.4.. 7i z��
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)
i 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)
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
g ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan) `afi V., --t--T\o
❑ ❑ 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?
gi ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
lA ❑ ❑ Is the well cap satisfactory?
'IA ❑ ❑ Screened and vented? n \v
❑ The well casing extends , U abov6 level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal?
❑ ® ❑ Does the seal appear adequate? V Kkt 5 7 S
❑ [21, ❑ Is a variance necessary for well site approval?
Comments 6-ei4'I-}ah'l .4.L Si-a I yVl KAf- l-C. ((}11v,Ylt pGc-t<-(,v-
p\-K2.% a -e...p i..5+-ci Ka -4--r��iv - .
Lai 4-1• Sl- 5t,1 Lori : - 12Z. t3`-ia6 (,
ill Pass ❑ Fail Inspector I ry%), Vv\„p (--(WA Date 'j3 I IL. -5
Review Step 2: Two-Party Review:
YlicrNO NA
LI ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test 2/J(,1 Z.Z Driller ;)A VI 5 _GPM lc
❑ ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test _ 2- I!`f/ ZZ
[N ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2 19 Z 5 7 3
1 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
Approved ❑ Denied Reviewer -- --) ,( \AZ-) Date 3/2__��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
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WATER WELL REPORT DEPARTMENT. OF Notice of Intent No.WE42541
ECOLOGY Unique Ecology Well II)Tag No.BKH 575
Type of\\nrk: irate
Si Constrain'', Site Well Name(if more than one well y
Decommission Original installation NOI No. Water Right PcrmtvCcrtiftcate No.
Proposed llse: It Domestic J Industrial Cl Municipal Property Owner Name Churchman Partnership
Desvatenng _Irrigation ❑Test Well CI Other
Well Street Address 130 NE Tiaer Lake Rd W
Construction Type: Method:
7r New well Alteration 3 Dnsen J limed A,Cable Tool City Belfair County Mason
_.Deepening C.Other 0 Dug J Air- Mud-Rotary Tax Parcel No. 12305210010,
Dimensions: Diameter of fixing 6 in.,to 400 R.
Depth of completed well 195 ft. Was a variance approved for this well? 0 Yes 0 No
Construction Details: WallII'yes.what was the variance for'
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
'iJ I 0 6 in. .1 160 1/4 in, Nl 1 ❑ II 10 Location(see instructions on page 2): 0 VWM or 0 EWM
O I ❑ B in. 210in. '0 O 1 0 NE -'/.of the NW w Section 5 Tonship 24N Range 1W
0 I E7 4.5 in. 115 195 195 sa 40 in. 0 I ® ❑ I ❑ 1/4-1/4
• 7 I l0 _in. _ _in. 71 I ❑ 0 I 0 Latitude(Example:47.12345)47.51759
Longitude(Example:-120.12345)-122.83504
Perforations: 0 Yes J No Type of perforator used
• No.of perforations Size of perforations in.by_in.
LoR/Cowxtnsetinn or Decommission Procedure
Perforated from_ft.to_ft.below ground surface Formation:Describe by color,character.size1 of materiel and structure,and the kin and
nature of the material in each laver penetrated.with at least one entry for each change of
Screens: Yes C7 No -'K-Packer ' Depth it. information. Use additional sheets if nccc-.ary.
Manufacturer•:Name iohnson
I ype plastic Model No. \tatenal From To I
Diameter 4 5 in. Slot sve saw Cut in from 160 ft.to 190 ft. Reddish brown sand&gravel 0 18
Diameter in. Slot ale in from R.to_ft. Brown sand&gravel 18 155
Sand/Fiber pack:7 Yes No Size of pack material in. Brown sand&gravel with water 155 195
Materials placed from ft.to_ft. Red conglomerate 195 260
Surface Seal: W Ycs C No To what depth?18 ft. Wet gravel 260 268
)laicise)used in seal bentoniteReddish brown conglomerate 268 300
Did any strata contain unusable water? ❑Yes J No Tan sand&gravel 300 365
Type of water? Depth of strata Light brown silts&sand 365 380
Method of sealing strata off Wet brown sand&gravel r 380 398
Pump: Manufacturer's Name arundfos Type sub Green silts 398 400
Ii.P. 1 Pump intake depth:180 R. Designed flow rate 12 gpm
Water Levels: land-surface elevation above mean sea level_ft. casing cut with down hole cutter ft 210
Stick-up of top of well casing It.above ground surface '
Static water level 124 ft.below top of well casing Date lower bore hole&casing filled with bentonite
Artesian pressure_lbs.per square inch Date to 195.Upper casing retracted to 160'
Artesian water is controlled by , cap,salve etc.)
Well l ests:
Was a pumping test perfuntied? C No f]Yes =J by whom?
Yield_gpm with_ft.drawdown after_his.
Yield_gpm with_ft.drawdown after_hrs.
Yield_gpm with_ft.drawdown atter_his.
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 15 gpm with 11 ft.drawdown after) his.Air test_gpm wish stem set at_ft.for his I-. Date_
Artesian flow gpm
Temperature of water_°F Was a chemical analysis made' Yes `]No
Stan Date 1116(22 Completed Date 2116l22
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.
l0l Unllav E Trainee 0 PE-Print Name Emily Davis frilling Compare Davis Drilling
Signature Address 340 NE Davis Farm Rd
License No.3142 City,State.Zip Belfair,WA 98528
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.DAVISSI110OA Date FEB
• ECY 050-1-20(Rev 08/19)If you need this document in an alternate format.please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can cull 7/1,firr Washington Relay Scrvie e. Persons with a speech disability can cu11877-833-6341.
1786 SE Mile Hill 11
N:xtorcDharo.wA I SPECTRA Laboratories - Kitsap
98366 ...Where experience matters
COUFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
2 ' 1 '.Month . Z? \J_: � P 1'Y&sov
Type of Water System(check onl one box) /°�—}—�—
❑Group A Ems' Other y
Group A and Group B Systems—Provide from Water Faci ities Inventory(WFI):
IDft 1 r f^I� r �Q
System Name: C� /v r C r''`-"1�y — �`g f� Ck
Contact Person:
Day Phone:( ) Cell Phone:(
Email:
Send results to:(Print full name,address and zip code e-mail)
SAMPLE INFORMATION
Sample collected by(name):.�,�.,�
Specific location here sam e ( S •clal instructions or comments:
VW I
4-441
Type of Sample(select only one type of sample from types 1 through 5 below)
�-1-11 iutine Distribution Sample(A!P) 2.❑Repeat Sample(AIP)
`.+4. Chlorinated:Yes No X (from dismbu6on system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample —— — — — •
S Unsatisfactory routine collect date:
i�
Chlorinated:Yes No
❑Triggered(AIP)
Chlorine Residual:Total Free
❑Assessment (AIP)
4. Surface or GWI Raw Source Water Sample(Enumeration) I I
S
L
❑ 011 ❑Fecal FJtered Yes No
5. ample Collected for Information Only:
USE ONLY DRINKING WATER RESULTS USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
❑E.co r present ❑E.coli absent
Bacterial Density Results:Total Co:iform monn I100m1. E.coll men/100m1.
Fecal Coliform cfu /100m1. HPC /1 ml
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damagedontalner ❑
Da; lc4 LULL Lab Reference Nu5� O
Receipt Temp C° Method Code. 1922 or SM9222D
Date Reported to DOH Lab Use Only
DOH LabSample#
225- U 2,
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2192373 MASON CO WA co w
01/03/2023 01:14 PM NOTCE
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PHINNEY #183153 Rec Fee: $204 50 Pages 2
Return To 111111111111 1 III I01 II II 1 III 11 III III 1111 I III 11111 II T"3" GB
More i n v
110,83 Ci/P r
_S1'I vEraJ 13 3
Grantor(s): (1) MoliE (, UrChYY)a P /w8i<
M Churchry)a
Grantee(s): (1) PUBLIC
Legal Description (1)
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) ) 2 1 0 c - Z I - D O I
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 r) .5 - 1 - 0 C i 0
Tax Parcel: (Connection 2) 1 % 3 o c - a - c) 1 0 a
The system owner is responsible for keeping this system in 'compl)ance.
The name of the water system is: V r Ma I W chi-t 1"-
This system is designed to provide for two service connections. Planning and design ap royals
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 3 rcl day of_Ian°a ry , 20 20.
Signature of Grantor(s):
4,1k
(111-67., 4t/Y-171(
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 3/16 day of Itiv, , 20 23 ,
Mode. Chw«'n�+aa ?h;nrt f 111ariC 011101per nally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and y-ar last above written.
Notary Public .A!,
State of Washington
ARIANE M PAYSSE Notary Public iiin�an f the ate of a hington,
MY COMMISSION EXPIRES residing at ) aZp7 (
12/29/2025 My commission expires: rZ/2, 21? 5
Page 2 of 2