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HomeMy WebLinkAboutWEL2023-00018 - WEL Application, Design, Letter - 4/11/2023 MASON COUNTY 415 N 6TH STREET,SHELT ,E 400 98 SHELTON:360-427-9679670 EXT 400 J(, 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©masoncou ntywa.gov Sincerely, Rhonda Thompson Environmental Health Specialist Mason County Environmental Health "` PPrr.tt.tc4 Date Received: ( { 7 ( -- Z 3 �;� MASON COUNTY f` ,. a COMMUNITY SERVICES A�du S Recei B �- = !y. Building,Pbnn ing,Environmental Health Community Health 415 N.6"Street,(Bldg 8)—Shelton,WA 98584 W E L tj, U - _ ' U w l 8 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION ..__ J=rl/�...- �•--,-•--.."- ,-r�__�-___.__�...,-:,_�.__ , ___� r.-._.. .r _ r -cam ...- APPLICANT PHONE de�� j a.1.0m 2573 691 - 6 MAILING ADDRESS-STREET,CITY,STATE,ZIP ` 2Lia c �Gkewa‘ Di-. 1 0f, , wA 1Is8 v SITE ADDRESS-STREET,CITY,STATE,ZIP PRIMARY PARCEL NUMBER(WELL SITE) I —).. , 3 2 kt (L v © °.ccct���b_ ScCUND9$Y PgRCEL�U .L._.c C C` €' a WATER�SOeUU,RCEE " SUunt.c,r rc PARCEL I LOT SIZE PARCEL 2 LO S 0 New 17'Existing I ,Well 0 Spring eV,Gt—i I , (' PROPOSED WATER SYSTEM NAME(REQUIRED) fa.4-75 well PROJECT DESCRIPTION LAse- cA-t54-t^,_.5 (A..ie.11 ct-i- 2.s0 E I_..a-41,a4Y . +0 Gis 5M9f I t.,,a <r +0 2 9 a E. L or-- L 4G.y Dr• DIRECTIONS SITE/CONDITIONS rclG/t Rol f6 � 0✓� E. L4�CLJAy V a-. ( iJ^v./4Jf f454- Be., 4-/ -; iy ) ` Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) APR 14 2023 ill i_i'd � By Submittals Checklist: (these additional items will be required for approval) Cr Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) iffibVell Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) A5 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: // 01 YES NO NA ❑ ❑ 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, County or State. What is distance to ROW? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) El. ❑ ❑ Is the well cap satisfactory? 'XI ❑ ❑ Screened and vented? _ l 1 ❑ The well casing extends \5 above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? I ❑ ❑ Does the seal appear adequate? ❑ -V ❑ Is a variance necessary for well site approval? Comments t ' L(q , 2G b'-c1 ti i (mot - 122__ IS3 1100 gPass ❑ Fail Inspector -IrVi Date I 3)Z" Review Step 2: Two-Party Review: YES NO NA 't ❑ ❑ 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"7.7 17,?? 7. ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2\‘' 6 n(p ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments XApproved ❑ Denied Reviewer 0 Date C k g 17,3 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 196, 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 • --�4 (...___e " zT.w0e !I - 8°r. / §7<kc .l.x ifi D.31'025'71 . | q | [ |: r[ < R, \ ) # qt§ 0g0 I | p r / I Q § q| / P .,{ r | @ r , \ ` 217 !# 2 \ |f\ o i. E ! |f or M ..x \ I+ VI xk( 3 Rr |A-• ' ' ' ` } ! k k I� 000 ■ Ii , 4/0 /| K§ � P- .r l�xuo__. 2 0- _ » ° f \� ! k 6| v�lk �° |I / . w ( • { * i 4 3 X } [' c | o —, 644 ° . | 1. 1| 41 --• 40 • • / rd ■II 2 ' X , P ; I I1 § $ ] • P, »lga � i 0 ° oct �- & .ECx/ • o o0 \ / k aa , i , @ n ■ ! | k0,|g � k � k 0 � �q Aii m§ o I �� l _$ `PI ;\(&; � ;!® $ i //k x | • �a z § ` ° g . ©§ . | | o�r� ( k \} : [ \ r !Fi (• § ,§ , , �F� . i | | „ ,� . - Q < , f f ■ —— — § i s , 2.4 (\ § . . 0 ¥ -I -| \° ri P . \ 2 § 0 9 immiammumir WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE51216 ECOLOGY Unique Ecology Well ID Tag No. ABJ767 Type of Work: MI' State of Washington O Construction Site Well Name(if more than one well): f7 Decommission cz) Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: El Domestic ❑Industrial ❑Municipal Property Owner Name Jack Tatom ❑Dewatering 0 Irrigation ❑Test Well 0 Other Well Street Address 250 Lakeway Drive Construction Type: Method: O New well Ill Alteration 0 Dnven 0 Jetted 0 Cable Tool City Shelton County Mason O Deepening O Other ❑Dug II]Air- 0 Mud-Rotary Tax Parcel No. 22132-14-00090 Dimensions: Diameter of boring6 i to 155 ft. n., Was a variance approved for this well? ❑Yes O No Depth of completed well 154 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread RIO 6 in. 0 155 .025_ in. ❑ I ❑ 0 I ❑ Location(see instructions on page 2): li WWM or O EWM CIO in. in ❑ I 0 ❑ I 0 NW ''/.-'V..of the NW '/.;Section 32 Township 21N Range 2W ❑ I O in. _ in. ❑ I ❑ 0 I ❑ 0 I 0 in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47 12345) 47.266475 N Longitude(Example-120 12345) 122.952979 W Perforations: ❑Yes NI No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Formation:Describe by color,character,sue of material and structure,and the kind and Perforated from R.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: CI Yes O No K-Packer t> 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 g, Bottom at 150'9"-bailed down to 154' Diameter Slot size in.from ft.to fl. Installed screen Sand/Filter pack:0 Yes O No Size of pack material in. Materials placed from R.to R. Surface Seal: lil Yes 0 No To what depth? 18 ft. Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Yes El No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: 1l P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 195 ft_ Stick-up of top of well casing 1 fl.above ground surface Static water level 80.3 ft below top of well easing Date 1/20/23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) — \Vell Tests: \Vas a pumping test performed? 0 No 0 Yes t---J by whom? Yield spin with_fl.drawdown after hrs. Yield gpm with fl.drawdown after hrs. Yield gpm with_fl.drawdown after 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 Railer test gpm with_ft.drawdown after_hrs.- Air test 12 gpm with stein set at It.liar_hrs. - Date Artesian flow gpm Temperature of water 51 e F \Vas a chemical analysis made? 0 Yes E No Start Date 1/20/23 Completed Date 1/20/23 WELL CONSTRUCTION CERTIFICATION: l constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well constntction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller 0 Trainee O 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/I 8) if you need this document in an alternate format,please call the Water Resources Program or 360-407-6872. Persons with hearing loss cast call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Tl"c R • MANAGE.M ENT• Awk LABORATORIES eta.:, 1b11 eat et E,Tacoma,WA 9e494 `NW COUFORM BACTERIA ANALYSIS FORM • Data Sample Collected Time Sample County 1 . . Collected 4011 �wne Y.Y Oay r .( :t�.._Q" Type of Water System(died(only one box) GroupA ❑GroupB Other Group A and Groups Systems-Provide from Water Facilities Inventory(WFI): ID# tt _ System Name: lr c cropA Contact Person:.Arcadi9•pe1111ng, Inc Day Plane:(3 60) 426-3395 Cell Phone:( ) Erna: • •• Eve.Phone:( ) Send reruns to:(Print kg name.add*and.zip code) ArcAdia. Dkillinp, Inc Q f((I)t Po Box 1790 rni `__ (� err iAti 1? � Shelton, •tldl�i P.esv t� • 98584- • • SAMPLE INFORMATION Saf ipe collected by(name)' )` Specific location wham sample colle Special lnst,u ns or comments: 11 4� ' r C • type of$ample(select only one type of sample from types 1 tOig r,5 below) . 1.CrRol tn!Distribution Sample(AlP) 2 0 Repeat Sample(AlP) • Chlorinated:Yes No (from distribution system altar unsaL routine) • Unsatisfactory routine lab number: • Chlorine Residual:Total_Free__ 3.Ground Water Rule Source Sample $ I ( l Unsatbtactoly routine collect date: -----1 1 Chbrinated:Yes No ,, ❑Triggered(AlP) Chlorine Residual:Total Free ❑Assessment(MP) 4. Surface orGWI Raw Source Water Sample(Enumeration) s El E.col/ 0 Fecal Remo Yes_. No_._ 5.X.Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS •LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.colipresent ❑E.coll absent Bacterial Density Results:Total Coliform 1100m1. E.coil /100ml. Fecal Califon 1100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC El Sample too okl • ❑ Sample Vokime ❑Damaged Container ❑ DateMme R„ C : A ` 1� Lab Reference Number e k� RecefptTempC°: l+l� �tv Method Code' Date ported to DOH lab Use Orly: ?LAU O 4R DOH Lah Sample# l` — 2196068 MASON CO WA 04/18/2023 10:06 AM NOTCE 1 II1111110I 1 VIliii lii 1111 II i IIIII Iii III flll 111111 I1 III 2 Return To 2-40 E Lra1cr clay Dr ,.l n VUf 1gAsti 4 . Grantor(s): (1) �1c�Ck �. \ � o v� , (2)i Q.V\ � T a- k^n Grantee(s): (1) PUBLIC Legal Description (1) NW !Ai-'/y e C }1 k W%y Swillen 32 i'a,,.sk''p aim R443t ZW (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1)2 2 13 2 - l L( ,- 0 0 O g 0 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 ) 3 2 - I ,- D D 0 c 4 Tax Parcel: (Connection 2) 2. 2 ( 3 2 - L 4 - 0 O d S O The system owner is responsible for keeping this system in compliance. The name of the water system is: Ta 4-0 w. We l} 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 as not) been granted one or more waivers from specific provisions of the regulations. Dated on this day of 4 r rX! , 2O - . ign ture of rantor(s): 1) 2)'/ 1111 r Page 1 of 2 APR 18 2023 b By State of Washington ) County of bfiasert1 �Ao.tvl ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this 19 day of Ap cT( , 20 , -Jo,(es,,A` -Tataw 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. BRfTTANEY BUCK Notary Public in and he State of Washington, Notary Public residing at Glc&l//tYvti_ State of Washington r My commission expires: 1 Z " ZC3 Z.' I Commission*22005065 I My Comm. 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