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Home My WebLink AboutWEL2023-00012 - WEL Application, Design, Letter - 3/20/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 - P Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX: 360-427-7787 John & Kimberly Morris 724 Hi Crest Dr AUBURN, WA 98001 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00012 390 E Nicole Ln 220261090060 The 2-party water system, EisenMorr, 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 or email at Danderson@masoncountywa.gov Sincere , David Anderson Mason County Environmental Health i r. ,„4,,, (i ,., MASON COUNTY Date Received COMMUNITY SERVICES Amount Jf�ed: �O Recei �_`\\-• Building,Planning,Envirco mental Health,Community Health ,J-5 J 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 WE L, V -),; a V 6 l" O� Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elma:360-482-5269 x400 t TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT °�Q /k M�TaP ( NI\oCZtS PHONE 2 ✓ 3 r 7 4 0 , 4�.5 k MAILWOADDRESS-STREET,CnY,STATE,2'P � �� ` 9�t ? 24 \3 Crzcs-c SITE ADDRESS-STREET,CITY.STATE,Z�A\O E ` V` I LZ L O S \-‘ -c--L t ( ✓u .3t> PRIMARY PARCEL NUMBER(WELL SITE)2,.W2O , 9 oop SECONDARY PARCEL NUMBER(IF APPLICABLE) � �` L to 0070 WATER SOURCE SOURCE TYPE PARCEL 1 LOT E PARCEL 2 LOT SIZE'0 New Existing 50 Well 0 Spring \,Up ' +10 AC r PROPOSED WATER SYSTEM NAME(REQUIRED) E 1 s�l ��c-� PROJECT DESCRIPTION - ` f C Q i k -" lN` i�tk1.1�.�C �eP1it S 4s svt3Mr i) '3 -l0 - '? b DIRECTIONS TO SITE/CONDITIONS ACE K uz�-7-- o ,mu v CoLL Lr-ti ® E vv rZS 8c) Co lNUE -VD 410 \ .C.DLE Lt� Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways, roads,septic/sewer components and lines,easements,etc...) pi fid IETT U MAR 2 0 2023 By Submittals Checklist: (these additional items will be required for approval) 1. 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) f$1 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 ❑ ri ❑ 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, bounty or State. What is distance to ROW? -t ] ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? li ❑ The well casing extends Z. above level ground/concrete slab? (circle one) X ❑ ❑ Is there evidence of a surface seal? ( ( ❑ ❑ Does the seal appear adequate? ❑ ❑ Is a variance necessary for well site approval? Comments GCtCq I rCl7 • -I .?, 1 f c� gc y f, —1 2.2' ge66, . I y Pass ❑ Fail Inspector ,� Date 2/Z Z/2�/2 Review Step 2: Two-Party Review: YES NO NA jlt ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test Driller GPM ig ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test //_3I2 I/ZO?� ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z (7� ,SC'L [l ❑ El System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer ,<i Date 9/(1/?03 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 19h,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 i nme Thurston County is WA g8502 2000 Lakeridge Dr.5W •OIymp 360 867 2631 T}{URSION COUNTY COLIFORM BACTERIA ANACountyLYSIS Time Sample Date Sample Collected Collected ppm awe) Day Vox Private Household Type of Water System(check only one box) ❑Group A ❑Group B ❑Olher_._-_ - _ Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IOR System Name: ,�.-t MLA Contact Person: \M f-• Day Phone:( ) tom- Cell Phone:(2,63 yt,A ( R 5 L vti Phone:( ) Email. �:�, Send results to.(Print tun name,address and zip code or email address)� :1 r � 1N t t`,�nn\`7 v S SAMPLE INFORMATION Sample collected by(name). vice Specific location or address where sample collected: Special instructions or comments. Type of Sample(must check only one box of#1 through#4 listed below) 1.1, Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes No ❑Distribution System Chbrine Residual:Total_Free Chlonnated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coli-GWR(A/P) ❑Fecal-solace.owl,wrings l unerabon) Unsatisfactory routine lab number: Filtered.Yes No __ - _ ❑Assessment Monitoring(ALP) Unsatisfactory routine collect date ['Omer ! ! S 4.0 Sample Collected for Information Only Investigative Construction I Repairs- Other. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and aoSatisfactory 0 Eta present 0 E.cofi absent No Coliform detected Replacement Sample Required: 0 Sample too old(>30 hours) 0 TNTC 0 Bacterial Density Results:Total Coliform /100m1. E.coli /100mi. Fecal Coliform /100m1 Enterocood /100 ml. Method Code::$M 9223E ❑SM 9222D Date and Time ❑SM 9215B ❑Enteroler10 2 / iYl f 2 Date and Time Analyzed: 3 ,) I • 2 ?, Date Reported: Sampe Number(DOH number plus No dpts) lab Use Only 0 8 0 • L.) DOH Fain$331-319(revised o1n6) IC.-? i, i. � �r 01 WATER WELL REPORT CURRENT Notice of intent No. WE06235 Original&I"copy-Ecology,2"copy-owner,3'4 copy-driller i.'c'0'i t c'i' Unique Ecology Well ID Tag No. ALN338 Construction/Decommission ("x"in circle) . 0Construction ?61458 WaterRightPermitNo. EXEMPT WELL ElLLDecommission ORIGINAL INSTAATIONlrce Property Owner Name LSPI EXCHANGE of Intent Number Well Street Address 502 E.NICOLE LANE PROPOSED USE: m Domestic 0 Industrial 0 Municipal City SHELTON County PM 0 De Water ❑Irrigation 0 Test Well ❑Other_ Location_NE1/4-1/4 NE 1/4 Sec 26 Two 2or R 2W ewM ❑c r to TYPE OF WORK Owner's number of well(if more than one) WWM ❑one m New well 0 Reconditioned Method Dug CI Bored 0 Driven Lat/Lon (s,t,r Lat Deg Lat Min/See ❑Deepened �]Cable 0Rotary ❑Jetted g DIMENSIONS: Diameter of well 6 inches.drilled 120 ft Still REQUIRED) Long Deg__Long Mitt/Sec Depth of completed well 119 fl. CONSTRUCTION DETAILS Tax Parcel No. 220261090060 Casing (]Welded 6 " Dian from +l ft.to_i 11- __ _ft. Installed: Liner installed " Dianfrom____ft to fl. CONSTRUCTION OR DECOMMISSION PROCEDURE 8 Threaded -" Diann.from-_ _ft.to- ft - Perforations: ❑Yes QjNo Formation: Describe by color,character.size of matenal and structure,and the kind and nature of the matenal in each stratum penetrated,with at least one entry for each change of Type of perforator used.-- - information. (USE ADDITIONAL SHEETS IF NECESSARY.) SIZE of perfs_ in.by in and no.of petit from_ft.to_ft. MATERIAL FROM TO Screens: ❑Yes m No 0 K-Pac Location -_ - BROWN SANDY LOAM 0 2 Manufacturer's Name BROWN GRAVELLY SAND,LOOSE,DRY 2 12 Type — — _ — Model No BROWN PEA-GRAVELLY SILTY SAND,LOOSE 12 51 Dian:. Slot size from ft.to -_-ft. Diam.__ Slot size _from_ _ ___ft.to ft. GRAY SANDY GRAVEL,LOOSE,DRY 51 60 Gravel/Filter packed:0 Yes m No 0 Size of gravel/sand BROWN SILTY SAND,LOOSE,MOIST 60 89 Materials placed from - _---R to R. BROWN GRAVELLY SILTY SAND.LOOSE, _89 Surface Seal:(]Yes ❑No To what depth?20 ft. MOIST 105 Material used in seal BENTONITE CHIPS ___ BROWN SILT: BOUND SANDY GRAVEL, 105 Did any strata contain unusable water? ❑Yes 0 No LOOSE,WATER 120 Type of water? - - ____Depth of strata ____ Method of sealing strata off PUMP: Manufacturer's Name ___- Type: -- - H.P. WATER LEVELS: Land-surface e'er anon above mean sea level ft. Static level 63 - - ft.below top of well Date 4/10/07 Artesian pressure _-.lbs.per square inch Date___, -_ _ Artesian water is controlled by_--_- _ _..__ (cap,valve,etc.) W Et.L TESTS: Drawdown is amount water level is lowered below static level Was a pump test made?❑Yes m No If yes,by whom? _--- Yield: gal/min-with_-_ _ ti drawdown after_--_hrs. Yield: gal./min.with ft.drawdnwn after hrs. Yield: _ gal./min.with _ft drawdown after hrs " "--- Recovery data(time token Ctt rem when lwemp turned till)(water level atearured fm tit well d,..N✓g..s 9 `,: i::. top to water keel) Time Water Level Time Water level Time Water Level MAY /AA Date of test __ -- - - - -- Bailertest _gallrnin.with ft drawdown after hrs. I74,1?itrtilte(t of Lcoli)gy Airiest 20 -gal./min.with stein set at 100 ft.for I hrs. Artesian flow - ---_g.pm. Date _-- Temperature of water 51 Was a chemical analysis made? ❑Yes m No Start Date 4/10/07 Completed Date 4/10/07 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. a Driller 0 Engineer 0 Trainee Name(Print) BRAND[ONN HICCKS Drilling Company ARCADIA DRILLING INC. Driller/Engineer:Trainee Signature r` -i--+- Address PO BOX 1790 Driller or trainee license No. 2785 City,State,Zip SHELTON WA 98584 - "ifTRAINEE, • Contractor's Driller's Licensed Na Registration No. ARCADDI098K1 [)ate 4/13/07 Driller's Signature J Ecology is an Equal Opportunity Employer ECY 050-1-20(Rev 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report. 2195021 MASON CO WA 03120/2023 10 57 AM NOTCE MORRIS #185210 Rec Fee $204 50 Pages 2 Return To 111111IIIIIIIII IIIIIIIIII1III1 IIII IIIIIIIIIIIIIIIIIIIIIII IIIII III III IIII S n N K►►, v6er2L,- 7'24 N CREST" tom. • Ksc- Grantor(s): (1) � , (2) Grantee(s): (1) PUBLIC 7 - n D ��a� Legal Description (1) 1rZ l0 CF 1�1a0\tT LTt `t 5�" \O o A� (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 2 2 0 2 (o - l 0 9 0 0 (0 Q 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) 10 2 Ito_ - \ O - 9 0 0 (.0C Tax Parcel: (Connection 2) G- Q b - - 9 0_0 7 b The system owner is responsible for keeping this system in compliance. The name of the water system is: SEN MOQ2 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. 11 rr Dated on this i3 TK day of Tt f , 20, . Signature of Grantor(s): 4"<aill(11- 44 / (1)C ZtS1G t/ ( ) 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 day of f'jAcc tk , 20 , UC•/ ' !-1t4 personally 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 year last above written. (6 )(a ,,•, ..\ ;S%on F+�?, Notary Public in and for'the State of Washington, oo.�0 20�9;:FJ,'; residing at C.i LiY�'k L LB G `�� My commission expires: Oi-10 -- 1G2.4 . Pusoc '^ifi,• "Humbe`••av\��`� //pF" A1SN• W \ Page 2 of 2 rd y� • �+_ ' , . V K Q0 in 8 . 9 p¢U 1hII1I i1IIi ; !j �o Q pi p53o = s g = � W I I =%g a Q 6 p wc' 0 g O "'N L' . N O ' 2 t a,St"<t.ni = co g 0/". .tris3irrirunun- — — - 1-,,,Pn.8 d O — w w85§ w N LL IT V a a rc a w ¢ 1 Z( $ 12; 2 (../;#4 \'\ LL Z a y y 0 W® v _ pl L °'bo l w N i a N K \\ Z t G oo cu •' w Laipo 2 cc Z a 0 0 0 0 II J ( (n c of PGA 9,,-P