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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 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 rthompson@masoncountywa.gov Sincerely, Rhonda Thompson Environmental Health Specialist Mason County Environmental Health ` , Date Rece.ved. i. MASON COUNTY l _ 3 _ 42‘27 1 COMMUNITY SERVICES• mou eived Resew S - Building,Planning,Environmental Health,Community Health l 415 N.6'"Street,(Bldg 8)—Shelton,WA 98584 W E L a, - 6 000 1 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE /140 a fF LVAJ J -PH-!) N N F/ 3(.O, 7 -.7 I _ y 2` 4/ MAILING ADDRESS-STREET,CITY,STATE,ZIP `7 4 Ss G c,) PPt / - PL N LA..) SITE ADDRESS-STREET,CITY,STATE,ZIP / 3 Z N Tp Ca C/Z i 4- -- Yb uu PRIMARY PARCEL NUMBER(WELL SITE) 1Z30c — 2-I-eW" SECONDARY PARCEL NUMBER(IF APPLICABLE) I-2/3 0. --— -z/ — 00I o Z WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE Jew 0 Existing ,Nell 0 Spring HI I c S1. " I 1'' i(G 57-4 PROPOSED WATER SYSTEM NAME(REQUIRED) CH u eel f vi A rJ w D4- Z S y S 7''i PROJECT DESCRIPTION -Tiu a P w t LL. DIRECTIONS TO SITE/CONDITIONS OF F OF NE' Tit & LA-It Q'b tu s 7/ z4-&-- , Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) Rei- 0(.. 4 e---(1 LI JAN 0 3 2023 .J By Submittals Checklist: (these additional items will be required for approval) A 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) li Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) 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 Vi ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) 'VA , -}-1'\o l,( - ❑ pl ❑ 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? 1K ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) TA ❑ ❑ Is the well cap satisfactory? X ❑ ❑ Screened and vented? ❑ The well casing extends ._. a abovAlevel ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? C� ❑ ® ❑ Does the seal appear adequate? K' c 7 S ❑ Ca ❑ Is a variance necessary for well site approval? Comments '2- +Yl ( 0t I Virk, .f— C 0141 pt-e a(- a,r -r-t. 0-Ku-S at-o-e..pk - ry\N-u I( 4-t-iv, . Lai 4-1•51-15 K I r_or\ : - 12Z. t31/4'j it'ofo gl Pass ❑ Fail Inspector R I YY\ Date '13 I f Z 5 Review Step 2: Two-Party Review: Y NO NA ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 2-])(,1 Z Z Driller i)A VI 5 _GPM lc ❑ ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test _ 241 1/411 ZZ [N ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2 11 Z 3 7 3 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer —V Date _?/Z 2 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 19°e, 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 . Z ta,h k S t-it Z 6 ?to- flan Mask Gy,c)cc,hrr a� Z . .- ?oacCrl '1z30s-21- 0010X sl, 130 NE Ty Lake Rti VJ 3 SCof if : 1 - ` O 73 o a 20 ya lob 80 6 V t s h M i co *X ‘LIL) 0 la oF ..z. Jaz. 11111M:V:i..‘e).-4•11•1 to ''''',,, + m 4 _� K8 a „ 3 Audio-Visual Alarm' L M v - 14 A Cleanout ^ - 3en r► - ,,, ):_fm \ 2-----n - `' 0 1200 Gallon Septic Tank a '� d 2 Compaq tment with s — . � o Effluent Filter ) L \ ‘ O 4 1000 Gallon Pump Chamb '4) \ O5 Valve Control Box i \I +1 o . h L • [r--- Arr. ..A•%) . 4oI r 1r,\y' , oili,, .. 54" R.. :•. r:, 1\ ....: i-I N;Gil• 57eu34G +41 6> .Q PAULA JOY JOHNSON .•9'�i ,aR s_D I'i / S L �� v MAR 2 3 1�t:ti s 1... y6'v . 4 WATER WELL REPORT DEFAR'S'EN. Or Notice of Intent No.WE42541 ECOLOGY Unique Ecology Well ID Tag No.BKH 575 Type of Work: i:arr�i vvocHrg+.oe Cdnutruetron Site Well Name(if more than one well): Decommission — Original installation NOl No. Water Right PcrmirCertificate No. Proposed Use: E Domestic Li Industrial 0 Municipal Property Owner Name Churchman Partnership Dewatcring ::Irrigation Ll Test Well 0 Other Well Street Address 130 NE Tiger Lake Rd W Construction Type: Method: -� ---- - - Lr New well 0,Alteration Driven 0 Jetted s Cable Tool Oily Belfair County Mason 0 Deepening r-Other C Dug '�Air- 0 Mud-Rotary 'fax Parcel No. 12305210010t Dimensions: Diameter of boring 6 m..to 400 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 195 R. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From lb Thickness Steel PVC Welded Thread M 1 0 6 in. *1 160 1/4 in. Al I E I 0 Location(see instructions on page 2): O WWM or 0 EWM RIO 6 in. 210 400 114 in. 0 I ❑ 1 I ❑ NE 'V4-14 ofthe NW '4:Section 5 Township 24N Range 1 W 0 I © 4.5 in. 115 195 Sc 40 in. ❑ I l ❑ 1 ❑ 7 I n _in. _ _ in. 71 I r7 0 I 0 Latitude(Example:47.12345)47.51759_ Longitude(Example:-120.12345)-122.83504 Perforations: Ycs E No Type of perforator used No.of perforations Size of perforations_in.by!in. DrillK'a Log/Construction or Decommission Procedure Perforated from_ft.to ft.below ground surface formation-Describe by cokir.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: Yes 0 No T K-Packer Depth_ft. tnlor oration. Use additional sheets if necessary. Manufacturer's Name lohnsnn - -type plastic Model No Material From To Diameter 4.5 in. Slot sve saw Cu)in.from 160 ft.to 190 fl. Reddish brown sand&gravel 0 18 Diameter m. I Slot sve in.from ft.to ft. Brown sand&gravel 18 155 Sand/Filter pack:=Yes 7 No Size of pack material_in. Brown sand&gravel with water 155 195 Materials placed from ft.to 0. Red conglomerate 195 260 Surface Seal: E Yes C No To what depth?18 h. Wet gravel 260 268 Material used in seal bentoniteReddish brown conglomerate 268 300 Did any strata contain unusable water? G Yes ❑No Tan sand&gravel 300 365 f Type of water! Depth of strata Light brown silts&sand 365 380 Alethod of scaling strata off Wet brown sand&gravel 380 398 Pump: Manufacturer's Name arundfos Type.Sub Green silts 398 400 11.P. 1 Pump intake depth:180 R Designed flow rate 12 gpm Water Levels: land-surface elevation abuse mean sea level_ft. casing cut with down hole cutter 210 Stick-up of top of well casing_ fl.above ground surface lower bore hole&casing filled with bentonite Static water level 124 ft.below top of well casing Date • Artesian pressure lbs.per square inch Date to 195.Upper casing retracted to 160' 4nesian water is controlled by (cap,valve.etc.) Well Tests: Was a pumping test performed.' E No 0 Yes t3 by whom? Yield_gpm with ft.drawdown after_hrs. Yield gpm with ft.drawdown after_hrs. Yield gpm with_It.drawdown after hrs. ---� Recovery data'time-zero when pump is turned off-water fend measured from well top to water level) Time Water Level Time Water Level Time Water Level - - Date of pumping test (Jailer test 15 gpm ss nh 11 ft draw down aftcrl hrs. Air test gpm w ith stem...et at_ft for hrs. Date Artesian flow gpm Temperature of water "I Was a chemical analysis made" 0 Yes 0 No Stan Date 1116122 Completed Date 2I16122 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. Driller C Trainee 0 PE-Prtnt Name Emily Davis Drilling Company 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.DAVISSI1100A Date FEB FEY 050-1-20(Rev 08/19)/%you need this drx•untent in an alternate format.please call the Weller Recsourcrs Program at 360-407-6872. Persons 14th hearing loss can call 711,for Washington Relay Service. Persons with a specrir disability can call I77-833-634/. I; 1786 SE Mite.Hilt 1 Hortora,aro.wA SPECTRA Laboratories - Kitsap . 98366 ~ ...Where experience matters COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 2 ' IS. Z7 J : 26 ` rYl.&SO V Year Type of Water System(check onl one box) ❑Group A p=E Other pr►'v et- --- Group A and Group B Systems-Provide from Water Foci ities Inventory(WFI): IDif System Name: v(� h v rC i^t `"r►M/11 'mi in — in).e f ( l Contact Person: , Day Phone:( ) Cell Phone:( ) Email: Send results to:(Print full name,address and zip code e-mail) -Ctijk.V.1-&--Ar-i\‘I --.I.alif5T-Ii1.0";1-.:Celirt+\.- - SAMPLE INFORMATION Sample collected by(name):r l Specific location here sam e collected: S dal Instructions or comments: , II Type off Sample(select only one type of sample from types 1 through 5 below) �—r.(�rtoutine Distribution Sample(A/P) 2.ElRepeat Sample(A/Pt 415Chlorinated:Yes No X (born distribution system after unsal.routine) t‘ Unsatisfactory routine lab number: Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample ——— • S I I 1 Unsatisfactory routine collect date: . I__J Chlorinated:Yes No ❑Triggered(AP) Chlorine Residual:Total_Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) ISI I I ❑ oli 0 Fecal Rued Yes_No 5. ample Collected for Information Only: USE ONLY DRINKING WATER RESULTS USE ONLY ❑Unsatisfactory Total Coliform Present and atisfactory 0 E.coli present 0 E.coli absent Bacterial Density Results:Total Coliform mprt I100ml. E.coll mpn 1100m1. Fecal Coliform cfu 1100m1. HPC /1 ml Replacement Sample Required: ❑TNTC 0 Sample too old 0 Sample Volume 0 Damaedrr��gontainer 0 Datrgolq 1 4 LULL I S 5 Lab Referertceiure`11. O Receipt Temp C*: Method Code.1 92 or SM9222D Date Reported to DOH Lab Use Only* DOH Lab-Sampler! 5 Ll L 1 U 2, DCC For MJ314'9(dfttfw G6117(•It you ncod Ws pLbrlca0on n an altarnatlw'onrstl d 900S755t27(T057IT'all MI). T•is a C odw Ntecalorn are ave0atla Y.wae.dM.w2govldnnklvwsLvr. 2192373 MASON CO WA W 01/0312023 01:14 PM NOTCE PHINNEY #183153 Rec Fee: $204 50 Pages: 2 ��. Return To 111111111 IIIII tD1I I���I I��I l']rvG MoriE nn£� w o I I , i 1�83Cl' r Iv1 S)'I vFr "1` WA `13g3 Grantor(s): (1) Mo(,E CilU►'China 1 h) �� ark M u'1Vrciwia Grantee(s): (1) PUBLIC Legal Description (1) (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) I 2_ 3 .0 2-. 1 - Q Q 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) 1 3 n 5 - 1 - t) C ' Q Tax Parcel: (Connection 2) 7 3 o .S .- 2. I - d 1 a 2_ The system owner is responsible for keeping this system in compliance. The name of the water system is: 5)ordimari 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 lant)a ref , 20 20. Signature of Grantor(s): 6tizszcogrkci.,,04.,ki,nria,z, 7e 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 3e6 day of Jc,,,,,, , 202,3 , (Marie. C+nw t`ntmeM Nnrt f Marl Chw«►+per 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 in an �fv,the ante of a hington, MY COMMISSION EXPIRES residing at ,U)-&� ( `'� 12/29/2025 My commission expires: 12/29 20 5 Page 2 of 2