HomeMy WebLinkAboutWEL2023-00012 - WEL Application, Design, Letter - 3/20/2023 MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
, -,-;---7 :j
BELFAIR:360-275-4467,EXT 400
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 ,
G h
David Anderson
Mason County Environmental Health
I r
". ;.r^,,,t.,,t. MASON COUNTY Date Received: - O ' .)27
COMMUNITY SERVICES Amount eceved: Receirtv---,
-� S�.s
Building,Planning Environmental Health,Community Health
415 N.6ih Street,(Bldg 8)-Shelton,WA 98584 W E L (7 TL' 6 (2 6 1- ' ,,
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO—PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT 1 0\N "' � 4 i\Noerzt PMONE1 ✓ ,7 lO , 4 ,/\
MAILING ADDRESS-STREET,CITY,STATE,ZIP
7 24- \A Cczcs-r c2., AveposZ i ,�31\ 9B00 t
SITE ADDRESS-STREET,CITY,STATE,ZIPA\O L-0 ` \AA` 5 ��t t S /VI
PRIMARY PARCEL NUMBER(WELL SITE)""LO 2 \�9 0^tO
SECONDARY PARCEL NUMBER(IF APP/1 Pil 0 '�•., ) i`�,., 00 7 C
WATER SOURCE SOURCE TYPE r��/ PARCEL 1 LOT PARCEL 2 LOT SIZE
0 New ,Existing 10 Well 0 Spring \ 'IA 1 0 t O kr cj r,,
PROPOSED WATER SYSTEM NAME(REQUIRED) ,_,-
- S ew \b��
PROJECT DESCRIPTION 1 f L. vT ,
�� i�. S1 S P>M 5U `'t" `3 - \o ' V)
DIRECTIONS TO STTE/CONDITIONS LOLL- LvA ® 12„c3 Sc)
CoKrc ‘N1uE. -vo 4 t 0 �Ie LE L
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways, roads,septic/sewer components and lines, easements,etc...)
Via% k--cA tAu E )
MAR 2 0 2023 li/
kc?
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)
)$I 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)
[g] ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road/Private,rivate,\l�ounty or State.
l What is distance to ROW? J
X ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? 7/ 11
❑ The well casing extends Z6 above level ground/concrete slab? (circle one)
0 ❑ ❑ Is there evidence of a surface seal?
cif ❑ ❑ Does the seal appear adequate?
❑ ❑ Is a variance necessary for well site approval?
Comments toCq 4C/? . Li 7, I y U F6^7 y `j 2 2, g 663 l y
APass ❑ Fail Inspector 2,2.----- Date J/22/202-3
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file?
;ii
If NO, date of Capacity Test Driller GPM
4 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 3/21/20 7?
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z ( ' SCt Z
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
Approved ❑ Denied Reviewer ,,� Date LI/`( /Z C>Z 3
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`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
T County Environment
2000hurston Lakeridge Dr.SW •OlymPtar WA
Health 98502
111F- . 360 867-2631
• I11=��
_County
CTERIA ANALYST
Date Sample Collected Collected
3 12_0 i202 AM
: 0FV 5Ok tt
"ant oar Vox .i,Private Household
Type of Water System(check only one box)
❑Group A ❑
Group B ❑Other_.___--
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# __
System Name: may ( 1\1\c)r7
Contact Person: M\ �`--
Day Phone:( ) Cell Phone:aS3 I) l
E•mait:V p(� S = L 1 ve.Phone:( )
Send results to:(Pnnt full name,address and zip code or email address) r W
SAMPLE INFORMATION
Sample collected by(name) \/11�\
--7
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.�Routine Distribution Sample 2.Repeat Sample(after unsat routine)
Chbrinated:Yes No 0 Distribution System
Chbrine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free
❑E.col;-GWR(AIP)
❑Fecal-Sulam owl.spnngs(rwmerawn) Unsatisfactory routine lab number:
Filtered.Yes No - __ _
❑Assessment Monitoring(A1P) Unsatisfactory routine collect date
CI Other
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 L`].$atisfactory
• ❑E.coli present ❑E.coli absent No Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100mt. E.coli f100m1.
Fecal Coliform /100ml Enterococci 1100 ml.
Method Code:b.$M 9223B ❑SM 9222D Date and Tine Reed:01-:...
❑SM 9215E ❑Enterolerl® j 2 1 ) t et,-f 1
Date and Time Analyzed: .1 1 ( c -2, Date Reported:
Sarrpe Nurser(DOH nunber plus Iva dgas) tab Use Only:
DOH Form 1a31.319(revsedO1n6) ---
12
01 WATER WELL REPORT CURRENT
Original&1'copy-Ecology.2ie copy-owner.3 copy-driller
Notice of Intent No. WE06235
e'c'b'i'ti c'i Unique Ecology Well ID Tag No. ALN338
Construction/Decommission ("x"in circle)
ID Construction 61458 Water Right Permit No. EXEMPT WELL
❑ Decommission ORIGINAL INSTALLATION: once Property Owner Name LSPI EXCHANGE
of Inieni Number Well Street Address 502 E.NICOLE LANE
PROPOSED USE: 19 Domestic 0 Industrial ElMunicipal City SHELTON County M
❑DeWatcr Irrigation ❑'test Well ❑Other_
Location NE1/4-1/4 NE 1/4 Sec 26 Twn 20N R 2W EWM ❑ctrcte
F.TYPOF WORK Owner's number of well(if more than one) -
WWM O otte
0 well ❑Reconditioned uethal:p Dug 0 Bored 0 New
Cable
ed Lat/Long(s,t,r Lat Deg Lat Min/Sec
DIMENSIONS: Diameter of well 6 inches.drilled 120 ft Still REQUIRED) Long Deg_____ Long Min/Sec
Depth of completed well 119 ft.
CONSTRUCTION DETAILS Tax Parcel No. 220261090060
Casing m Welded 6 " Diam.from +1 fl.to_1 19-__ _fl.
IInstalled: 8 LLinerinstalled Ditun from __R to R. CONSTRUCTION OR DECOMMISSION PROCEDURE
Threaded " Diann.from fl.to ft.
—
Perforations: ❑Yes 0 No Formation: Describe by color.character,size of material and structure,and the kind and
nature of the molehill 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 perfs_from_ft.to ft. MATERIAL FROM TO
Screens: Oyes m No 0 K-Pac Location -- - - - BROWN SANDY LOAM 0 2
Manufacturer's Name _— BROWN GRAVELLY SAND,1.00SE,I)RY 2 12
Type __ - Model No BROWN PEA-GRAVELLY SILTY SAND,LOOSE 12 51
Diam. Slot sire - from ft.to ____-11
Dram. Slot size _from__ _-_.ft to__ fl. GRAY SANDY GRAVEL,LOOSE,DRY 51 60
Gravel/Filter packed:❑Yes m No ❑Size ofgraveUsand BROWN SILTY SAND,LOOSE,MOIST 60 89
Materials placed from _ _— ft to R. BROWN GRAVELLY SILTY SAND,LOOSE, 89
Surface Seal:0Yes ❑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 m 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 elevation shove mean sea level ft.
Static level 63 - - R.below top of well Date 4/10/07
Artesian pressure -- lbs per square inch Date___ -_ _
Artesian water is controlled by_- - ______-__
(cap,valve,etc.)
`WELL 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_-_ _ _ft.drawdown after _ hrs.
Yield. gal/min.with ft.drewdown after hrs.
Yield:_ gal./min.with _ _ _ft drawdown after-- hrs =►,l '" r....; r t i. ••.
t ..
Recorery data(lime taken err:ern".hut pump turned n/n(e oner lend nrem wed front bell I I 6.—N.,..."It..-1 '' i:.,-.
top to water level)
Time Water Level Time Water level Time Water Level
MAY f 5 LULU
—-- -- -- —— — - Watihul .t�I1 SUM
Date of test _-_ _
Bailer test _gal./min with ft drawdown after hrs. n4 l)Jrtltl'`It• of Ecology
Airiest 20 _gal./min with stein set at 100 ft.for I hrs
Artesian flow - g.p m. 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.
■Driller 0 Engineer 0 Trainee Name(Print) NDON rHICKS Drilling Company ARCADIA DRILLING INC.Driller/Engineer/Trainee Signature IIt/v16"...."- Address PO BOX 1790
Driller or trainee License No. 2785 City,State,Zip SHELTON WA 98584
(it TRAINEE:, ' Contractor's
Drillers Licensed No. - Registration No ARCADDI098KI Daft 4/13/97
Drilkr's Signature .IEcology is an Equal Opportunity Employer
\ECY 050-t.20(Rcv 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report.
2195021 MASON CO WA
03/20/2023 10 57 AM NOTCE
MORRIS #185210 Rec Fee $204.50 Pages 2
Return To I III II III II II 11111111111111111 III Ii11I II 1 1111111111111111111
3 n K et--2Ltf i\i\btaizt
72 -- N ► C_R.Esr t7r
Ac e um ;VK1A ')8co
Oc-5 �E '
Grantor(s): (1) �cc � � , (2
)
Grantee(s): (1) PUBLIC ` ,� (e'5.78S
Legal Description (1) Z t0 OF Q � t��' cc SPA °cob A
(Abbreviated form:fo i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 9.- (2- O - - (D - C) - 900bn
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) Z- 12- 0 2 - \ 0 - 9 0 0 (4, 0
Tax Parcel: (Connection 2) '2- 0 '2 t - \ 0 - 90 o b
The system owner is responsible for keeping this system in compliance.
The name of the water system is: \ SON \0c .
CZ
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. 1l
Dated on this i`� day of 1`� , 20,. .
Signature of Grantor(s):
(1)c.Tpi 1/7 A../ c/jevAletx./ , (2) 4 ,t,i1141,09/
//) )) 016440
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 Rt'kfi{k , 20 `a ,
DGwp.Ali E 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.
00;1(111W/0/ y .,'„,,at (--aclti4
�F• •\ssion F' �'y'6 Notary Public in and for hie State of Washington,
o.\0 20?,; c< • residing at Gi•L+L:)%4 4.L LB=
��} `� : _ My commission expires: Ci
r PUBl1G •?
thumb!
Page 2 of 2
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