HomeMy WebLinkAboutWEL2023-00027 - WEL Application, Design, Letter - 5/12/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, , E, E 400 98584
SHELTON: SHE T 967XT
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
KIBLER MICHAEL K
6959 BAILEY ST SE
LACEY, WA 98513
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00027
30 SE Orca Ln
320233100102
The 2-party water system, 30-90 SE Orca Ln Shared 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 or email at Danderson@masoncountywa.gov
Sincerely,
David Anderson
Mason County Environmental Health
�� L$`. mate Re:;eved
MASON COUNTY 5_ [a - ,
` ` : COMMUNITY SERVICES ,-nour:qec 1.,ec Rece,e.3
.'4ypo. .��/� Building Planning Envuonmenlal Health,Community Health
415N.6t Street.(Bldg 8)—Shelton.WA98584 WEL 20. O00Z1
Shelton: 360-427-9670 x400 Beltalr 360-275-4467 x400 Elma 360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT . PHONE
Michael K. Kibler ,aQ.\-Cl` 0@ V\tkinQl ( . CO`rn 360-561-2106
l MAILING ADDRESS—STREET,CITY,STATE,
\6959 Bailey SE
E ADDRESS STREET,— CITY,STATE,ZIP
90 Orca Ln, Shelton, Wa. 98584
PRIMARY PARCEL NUMBER(WELL SITE)
32023-31-00102 Lo l 6 (2v f )
SECONDARY PARCEL NUMBER(IF APPLICABLE)
3zoz3-3l -04 /OZ. L07L/9- (worfh)
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
❑ New ❑ Existing 2 Well ❑ Spring 1.4 Acres 1.4 Acres00000
PROPOSED WATER SYSTEM NAME(REQUIRED)
30-90 Orca Ln Share Well
PROJECT DESCRIPTION
Existing well on 30 Orca Ln has been provide water to 90 and 30 Since 1994. We need to record it
with the county .
DIRECTIONS TO SITE]CONDITIONS
Take Arcadia Rd to Orca Ln.
Site Plan: (may also be attached) Sow 4 irr4IC i- f)
(property boundaries.structures,,well site w/100'radius,driveways,roads.septicJsewer components and lines,, easements.etc...)
0)4 c 1 5e t-U lc-1,-lC .30 cf 0 0Q,e-G`f' L"1'V t — `i.1,-w viii.> of-L. Pi\-cL-('.
spq TT ,NG Pac,PF R '1'1t
a2e(: pi4.4J,O - dc13 /c
Submittals Checklist: (these additional items will be required for approval)
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)
Da 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:
1 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 roa• priv- County or State.
What is distance to ROW? ijd'
X ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ % ❑ Is the well cap satisfactory? 6Pe /5eq/ ' 1 ilcl Leo
❑ ❑ Screened and vented? I %
❑ The well casing extends ZS above level ground/concrete slab? (circle one)
M ❑ ❑ Is there evidence of a surface seal? t 1: 4q.Z006939
❑ ❑ Does the seal appear adequate? �0/) ;—I Z3.d ,3(�
pil ❑ Is a variance necessary for well site approval? i �4 p5C: ib •
Comments
T 0 Pass ❑ Fail Inspector 1 Date 5/16/70 23
a
Review Step 2: Two-Party Review:
i YES g NA .
❑ ❑ Water Well Report with adequate[ pump test on file?
If NO, date of Capacity Test 7/8/io CL �G/Z3 Driller Pf l/f� .hP1C�PM la
igl ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test sf/34011-3
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z19623 Z
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
)6 Approved ❑ Denied Reviewer 0Date S/ l y/ z Z3
r t
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. Hater
System approval is a two-part process.
.Ill proposed connections to new wells are subject to water adequacy requirements at time of building permit per:1-ICC 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
• 'WATER
MANAGEMENT
LABORATORIES arrc.
S 1616 5Oth St E,Tacoma,WA 95404
MEM
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected 1 Time Sample County
Collected
t� , 13 / 1 CLAN 4C C'n
Month Day Year
Type of Water System(check only one box)
0 Group A ❑Group B `!,[I Qther
Group A and Group B Systems-Provide from Water fjacili'6es Inventory(WFI):
ID# }-
System Name:�>l 12 j€\ 4( 0
Contact Person: Arcadia Drilling, Inc
Day Phone:( 3 6 0) 4 2 6-3 3 9 5 Cell Phone:{ )
Email: Eve.Phone:( )
Send results to:(Print full name,address and zip code)
• PO Box 1790 etsZ @fvAl t..1110+ ick
She.ltc_ri.,_ WA _ 9::
SAMPLE
rINFORMATION
Sample collected by(name):
Specific location where sample collected:` Special instructions or comments:
i. �(, �. �.I\€) .S
f 1 I
( T a of Sample(select onlyone type of sample from types 1 through 5 below)
Type P
1.❑Routine Distribution Sample(A/P) 2.0 Repeat Sample(NP)
Chlorinated:Yes No (from distribution system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total_Free •
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
01 I /
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total_Free_
❑Assessment (A/P)
4. Surface or GWI Raw Source Water Sample(Enumeration)
Isl I Ii
❑E.coil 0 Fecal Filmed Yes_No
5.'Sampe Collected for Information Only:
1LAB USE ONLY DRINKING WATER RESULTS LABM USE ONLY �l
❑Unsatisfactory Total Collform Present and 1�Satisfactory
❑E.coli present ❑E.coli absent ��„!!
Bacterial Density Results:Total Conform /100m1. E.coli _1100mI.
Fecal Coliform /100m). HPC /1 ml.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
�rrlme Received: Lab Reference Number
--
•
AL3• �;�� (ill tvvvW o
Receipt Temp C': 1.It;� Method Code: j 2. 7
(mil
Data OH 3 lab Use Only:
DOH Lab-Sample#
089
Arcadia Drilling Inc.
P.O. Box 1790
Shelton, WA. 98584
Customer: Michael Kibler
Phone: 360-561-2106
Well Site Address: 30 Orca Lane, Shelton
Date of Test: 4/13/2023
TIME GPM Gallons
1 Min 10.0 10.0
2 Min 10.0 20.0
3 Min 10.0 30.0
4 Min 10.0 40.0
5 Min 10.0 50.0
6 Min 10.0 60.0
7 Min 10.0 70.0
8 Min 10.0 80.0
9 Min 10.0 90.0
10 Min 10.0 100.0
15 Min 10.0 150.0
20 Min 10.0 200.0
25 Min 10.0 250.0
30 Min 10.0 300.0
35 Min 10.0 350.0
40 Min 10.0 400.0
45 Min 10.0 450.0
50 Min 10.0 500.0
55 Min 10.0 550.0
1 Hr 10.0 600.0
1 Hr 10 Min 10.0 700.0
1 Hr 20 Min 10.0 800.0
1 Hr 30 Min 8.0 880.0
1 Hr 40 Min 8.0 960.0
1 Hr 50 min 8.0 1040.0
Return 79 ? 2J1ASON19623 CO WA
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1 C , ,l,� $f u1RRPIICIVIRInINII DOM
4 A ce-y, t,c)c, . (7252_
Grantor(s): (1) /rr� />a�� h: '`> (2) — — - — —
Grantee(s): (1) PUBLIC
Legal Description (1)s,apte/ F,f R lb (1F6.L. 7 e-x Qk L /(yr€4,1) -f`
(Abbreviated form r e. lot, block, plat or section, township, range?)
Assessor's Tax Parcel: (1) 3 0 3 -. [ - O O / 0 "D,
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned granlor(s). certify that the water source located on the above-descnbea
real estate under Legal Description (1) and Assessors Tax Parcel (1) situated in Mason
County. State of Wasnrngton has been designated to serve a source of water to the following
parcels situates in Mason County, State or Washingtor herein descnbed.
Tax Parcel. (Connection 1). 2 3 - 3 / - Cc O.- I 0
Tax Parcel (Connection 2) _—_- __ —-__ _ -
The system owner is responsible for keeping this system in compliance.
The name of the water system is',,117-Qb Ca.C: .LA( Zjackst. Oki(
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 o'services.
Additionally, a water ngnt. obtained from the Department of Ecology is required 4 the water
system exceeds exemption standards
This system (hasi has not)been grantee one or more waivers from specific provisions of the
regulations
Dated on this / 9 day of f:'L 20 :-3
Signature of Grantor(s)
(1) (2) — — — --
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