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HomeMy WebLinkAboutWEL2023-00018 - WEL Application, Design, Letter - 4/11/2023 MASON COUNTY 415 N 6TH STREET,SHELT 98584 SHELTON:360-427-9679670,EXT 400 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 TATOM JACK D & JANET M 2727 SEQUIM DUNGENESS WAY SEQUIM, WA 98382 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00018 250 E LAKEWAY DR 221321400090 The 2-party water system, Tatom Well, 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 K.,..„.„7„-:,.•,.,,->\..., Date Received: y / �,� MASON COUNTY �{` 1\ "M. COMMUNITY SERVICES Amou : — Recei B y s: v+y,l. _. Building,Planning,Environmental Health,Community Health 415 N.6ih Street,(Bldg 8)-Shelton,WA 98584 W E L cp 2-3 - U( ( 1 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE j j c 1 for-. 25-3 61I - 61ti1 MAILING ADDRESS-STREET,CITY,STATE,ZIP 2LI0 t Lakewa./ Dr 1. 5 -)4--0ln , lAiA 5 c-,Ei 41 SITE ADDRESS-STREET,CITY,STATE,ZIP PRIMARY PARCEL NUMBER(WELL SITE)— 1,Tb.., l 3 ')'__ I c-k U 't V Stt;OND Y P RCEL NUI _ ....._.- `_ WATER SOURCE I SOUNVc,. PARCEL 1 LOT SIZE PARCEL 2 LO El New tit Existing 1 , (Well ElSpring (0 14-7 I PROPOSED WATER SYSTEM NAME(REQUIRED) PROJECT DESCRIPTION I ff 11 US2- 4rt5-V A� (..A--,ell a T ZSO E L.Gk4w G ay b1 +a is. 5Heply tc,fee-- +Q 29 c, E. L a t -tr),, Or• DIRECTIONS TO SITE/CONDITIONS tPTCkci1%,1_ RAP 4 c 0 v\ E LC,kt.t�A), Df. ( ISoWI5 Pa s4- gat e 4-G 11) Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) y.,e., Ci\.k-V -F)1\P"-A APR 1 4 2023 By Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) Er Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) LE 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 w --7____w____Staff Use Only ________:_M__ Review Step 1: Well Site Inspection: // YES NO NA ❑ IX Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ f�.l, ❑ 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? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Is the well cap satisfactory? X' ❑ ❑ Screened and vented? _ 11 ❑ The well casing extends \ J above level ground/concrete slab? (circle one) `l ❑ ❑ Is there evidence of a surface seal? • ' ❑ ❑ Does the seal appear adequate? ❑ ❑ Is a variance necessary for well site approval? Comments L ' Lf'� • 2G C41 V I 4 (15N 1 .' - !2Z, °l c 118 d fgf Pass ❑ Fail Inspectors Date I J bZ Review Step 2: Two-Party Review: YES NO NA 15i ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test Driller GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 1 17. (7,?7 ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 7i\6 6(%).-n IX ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments XApproved ❑ Denied Reviewer Date kt G 1 7 .75 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/l 3/202 I This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 • / ..,"„ iFi / R£« IH@E I�K� } 2 lq, &°27 ( !`|" 0 41 . 1. k Do n ] j ° [F @ V" Rƒt; ;' C. ki | /\ � § \ .��/ �4{ a9 r r. @ . . P.�. lib, , �� U y��4.k 2 ;-, , I � < 2, |\ a ; i ,.t, ! * a j , k1 C. ,/k z )i| O'\§ , �-5 7 /! ri§ /»«,4,. 2»', »�, `� �2 m 9, � , !'Ei| ¢ c E I ® �,774 ��, G �- .. . , !1_I , ���. x� ■� 4 r P V 2 . . » \ .1 , ro a r -• E E ��`22 9 7 \ ` o • ` § co it \ \ x , � f r �coa 0 ~,m r , 2 � r � \§� ? d No r)---) 'tS Z/q § I+ tg ;\( - 1 23 ;!® t f /7§ 2 ' CI z%f § - e g , , 2 § ■ oI9- \ k ƒ{ • o r ° ( . r `e a (\ { \ r ! , ) .—....?....> | ' - & — ---- -- --- ; s „ C , , _ $ CO _ . — s : .. ® ! rs r. , ;} ` , % . | �■ k (j / \ . /4 ` !di o . , WATER WELL REPORT .....b.4.A91 DEPARTMENT OF NoticeoflntentNo. WE51216 ECOLOGY Unique Ecology Well ID Tag No. ABJ767 Type of Work: gal State of Washington 1 Construction Site Well Name(if more than one well): fl Decommission ri Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: LC Domestic L)Industrial 0 Municipal Property Owner Name Jack Tatom 0 Dewatering ❑Irrigation ❑Test Well 0 Other Well Street Address 250 Lakeway Drive Construction Type: Method: ❑New well IC Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening ❑Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 22132-14-00090 Dimensions: Diameter of boring 6 in.,to 155 ft Was a variance approved for this well? Li Yes O No Depth of completed well 154 ft. Construction Details: w,ll If yes,what was the variance for? Casing User Diameter From To Thickness Steal PVC Welded Thread 13 I 0 6 in. 0 155 .025 in. ❑ 1 ❑ 010 Location(see instructions on page 2): ©WWM or❑EWM D I D in. in. ❑ 1 ❑ 010 NW y.-y,of the NW t/.;Section 32 Township 21N Range 2W DID in. in. ❑ I ❑ 010 ❑ 1 0 in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.266475 N longitude(Example.-120 12345) 122.952979 W Perforations: ❑Yes fit No Type of perforator used No.of perforations Size of perforations in by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to fl.below ground surface Formation:Describe by color,character,size of material and stnteture,and the kind and nature of the material in each layer penetrated,with at least one catty for each change of Screens: O Yes 0 No O K-Packer Depth 152 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Screens Material From To Type Wire Wrapped Model No Diameter 2" Slot size.010 in.from 152 ft.to 155 fl. Bottom at 150'9"-bailed down to 154' Diameter Slot size in.from ft.to ft. Installed screen Sand/Filter pack:❑Ycs I l No Size of pack material in. Materials placed front ft.to A. ' Surface Seal: IE Yes ❑No To what depth? 18 ft. Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Ycs O No Type of water? Depth of strata Method of scaling strata off Pump: Manufacturer's Name Type: I I.P. Pump intake depth: IL Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 105 ft. Stick-tip of top of well casing 1 ft.above ground surface Static water level 80.3 ft below top of well casing Date 1/20/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ©No ❑Yes t--J by whom'? Yield gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown altar 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 Date of pumping test Bailer test gpm with_A.drawdown alter_Itrs. Air test 12 spin with stein set at_ft.for hrs. - Date Artesian flow gpm Temperature of water 51 °F Was a chemical analysis made? ❑Yes fE No Start Date 1/20/23 Completed Date 1/20/23 WELL CONSTRUCTION CERTIFICATION: 1 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. IIl Driller O Trainee❑PE- ri ame Rogeray Phythian Drilling 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.ARCADDI098K1 Date 1/20/23 ECY 050.1.20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hewing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. WAIT it • MANAGEMENT AMIL LABORATORIES INc:. 1018 80tt,et E,Tacoma,WA 98404 MOM . COUFORM BACTERIA ANALYSIS FORM • Date Sample Collected Time Sample County �3 ! r)3 Collected +} Type("Water System(check only one box) ❑Group A ❑Group B 141alter Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: ti eft .`/tri--tvIA Contact Person:,Arcadis pri11 Lng, Inc Day Phone:I 360) 425-3395 Cell Phone:( ) Emat. Eve.Phone:( ) • Send resutis to:(Print in/hams,address and sip code) Arcadia Drilling, Inc fali PO Sox 1.790 *PifyIsp, 1 gt.ri Shelton, WA P.eSvt 9OS8d- .SAMPLE INFORMATION Sarnpie collected by(name)' SS location ere sample colle Special Oftcmrn.tti • 4.0- d,+, ; .fi n Tytjie d&ample(select only one type of tia(ppte kom ee0 ilggi i:5 blow) 1.❑aRoutIne Distribution Sample(AlP) 2:❑ Repeat Sample(AMP) Chlorinated:Yes No • (from distribution system after unsaL routine) • Unsatisfactory routine lab number: • Chlorine Residual:Total Free • 3.Ground Water Rule Source Sample — — — ` II I Urn ty'routine collect date: Chlorinated:Yes No • El Triggered(AP) Chlorine Residual:Total_Free_ 0 Assessment(AIP) 4. Surface or GWI Raw Source Water Sample(Enumeration) I 8 ❑E.coli ❑Fecal pad Yn__Ne_, 5. Pie Caleded fa Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifonn Present and Satisfactory 0 E.coli present ❑E.coli absent Bacterial Density Results:Total Coilform _l100m1. E.coll /100ni, Fecal Colrform /104ml. HPC li ml. . Replacement Sample Required: 0 TNTC 0 Sample too old 0 Sample Volume ❑Damaged Container ❑ DatefTime Received: lab Reference Number Receipt Temp C': Method Code: 1 J :&i: aQ LaabUlyUQR _ 2196068 MASON CO WA 04/18/2023 10:06 AM NOTCE JEFF II I III 111111111111111111111111111111 Rec Fee NI IIII II 2III � ReturnTo nn - ^ Z 4 0 E L a k• r.JA,r Dr S ) 1-0,, 'WA °le Se41 Grantor(s): (1) c_ Q... ��C o �� , (2)i Q.vN V/k •TaX 6 wt Grantee(s): (1) PUBLIC Legal Description (1) N W t/y -141 0c }1,4- N w%y $sc)'+'en 32 Townswp zii Ronje.7W (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) '2. 2 1 3 2. - 1 - O O cog o 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) 2 2 1 3 2- -1 y - 0 0 0 . 9 O Tax Parcel: (Connection 2) 2. 2. 1 3 2 - 1 LI ,- O O 0 S o The system owner is responsible for keeping this system in compliance. The name of the water system is: -Fa}Q wt 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 (hasf(tias not) been granted one or more waivers from specific provisions of the regulations. Dated on this i 5' day of A.p i , 202- . ign:ture of rantor(s): 1) Ic: _ i -� , 2)' -�- 1 1-j [ I 0 �> -Er Page 1 of 2 i_i APR 1 8 2023 By 1 -.. iimomor State of Washington County of Masers Ll o-\laovl. ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 15 day of Ap TiC , 20L-5 , -3u o„.o,` ` -Tatorn 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. BRITTANEY BUCK ( Notary Public in and he State of Washington, Notary Public ' residing at Glctllurn_ State of Washington My commission expires: 1 Z ` 2-8 ZS Commission i>`22005065 My Comm. Expires Dec 3, 2025 AINIPPIIMPROPTIOINWWwwiig Page 2 of 2 �' 70 U mO Tim --CD -I 7 rrn 70 -A0 m0 MOrnrn 3 z n O p0 p3 70 p < 74 � mCDI 1 19 TV Nrn J " �• Z 0 TppT z m079 U.) 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DESIGN BY: TATOM RESIDENCE TIM L. 240 E LAKEWAY DR ADAM LANEER DESIGN SHEI_TON, WA 98584 DATE: 04-/12/23 architecture I consulting