HomeMy WebLinkAboutWEL2023-00025 - WEL Application, Design, Letter - 5/3/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, ,WA 98584
SHELTON:360-427-9670,EXT 400
~ BELFAIR:360-275-4467,EXT 400
t, Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
C Estrada Inc
11659 SE Black Rd
OLALLA, WA 98359
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00025
361 E Mclaine Cove Dr
121073250300
The 2-party water system, Estrada Water System, 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
D id Anderson
Mason County Environmental Health
111111m—
MASON COUNTY late Received: 5 13 o
COMMUNITY SERVICES Amount Reed: Rfved e
,P\;,,,,. Budding Planing,Environmental Health,Community Health
415 N.6th Street,(Bldg 8)-Shelton,WA 98584 W E L (O J - b 0 0a S
Shelton: 360-427-9670 x400 Bei1air:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT
—
C LS . In L. i PHONE(2- ) 31 U i)9 2S
MAILING ADDRESS-STREET,CRY,STATE,VP
- - lI6s? SF f lack Rd 014 LI-A rittiftQWWS'
SITE ADDRESS-STREET,CITY,STATE,ZIP /'� qQ VI I .�
7�1 f- t:1 tt i✓II. ( o i - 0l( CA(12.\/tt W 1l°') 1 tX
PRIMARY PARCEL NUMBER(WELL SITE) i
17 10 132cO30o
SECONDARY PARCEL NUMBER(IF APPLICABLE)
IZ10132c0100
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SCE
0 New IliExisting X1 Well 0 Spring I. CS f c', CZ—
PROPOSED WATER SYSTEM NAME(REQUIRED)
VI.- liCek.CJLG.
PROJECT DESCRIPTION
2"- _ tr w21
DIRECTIONS TO SITE/CONDITIONS
+ra� ti\C-1W►L CI\I) 4 ) 5 0-4- () IA 1-t_.0- , a t vkt 0 -1- {-LD
k
Site Plan: (may also be attached) _
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
12AO12)1- %aiCU
.371'
c,,c,e,„41, 41-1
.$3,,,Y_____________
V�ALL �„
1 --
1 2-1 n 1D-2-S-0 3 C C)
Submittals Checklist: (these additional items will be required for approval)
ISatisfactory 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)
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
StaffUse Only----------------------------------------------------------
Review Step 1: Well Site Inspection: _7F‘ .10 Strike1 blch 5t'f i(?F j09a/ d'") a4'fi'eZe/Co01c,.i -
YES NO NA - 5 '40 (GOc(
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
6 ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is roac riv te, County or State.
What is distance to ROW? erg
f] 0 0 Does the ground slope away from�thCe water source site? (show slope on plot plan)
I ❑1 Is the well cap satisfactory? f}I'l 'f/"r m(Nl'/i3 It Ns ckst «�
0 0 Screened and vented? i
CI The
The well casing extends Z I above level ground/concrete slab? (cir a one)
171 0 0 Is there evidence of a surface seal? l.pf Lq,.?l 1,1 6:15-
❑ 0 Does the seal appear adequate? Loll: -1Z Z. 8'61f zi)y
❑ j 0 Is a variance necessary for well site approval? TGy , OT H 075-
Comments ill/ -v r marVr fir t is- ke 1I ttet c Gi►'j°i lose. L
�> 61z02i 1 ' is tit I Wro c rha�J
1
/kcPass ❑ Fail Inspector ��� Date 5(16770z ,
Review Step 2: Two-Party Review:
TiS NO NA❑ —
0 Water Well Report with adequate pump test on file?
If NO,date of Capacity Test Driller GPM
N ❑ 0 Received Satisfactory Bacteriological Analysis? Date of test yi 4'7 Zt Z3
0 0 Received Signed, Notarized, and Recorded Notice? AFN ZI 9 66.75
10 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments 6/77zazy: I2 e- ftc1c'rJ of (leafy.
Alf Approved ❑ Denied Reviewer Date 6(5/ Z3
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.
0 ._
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 2 of 2
•
WATER WELL REPORT CURRENT
ortetnal to 1"copy-Ecology,re copy-owner,3"copy-drtlrer Notice of Intent Na WE22780
1. arututer or
ECOLOGY Constructlon/Decommisslon("x"in circle) Unique Ecology Well ID Tag No. B1H075
® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION Property Owner Name Shawn Slade
Notice of Intent Number _
PROPOSED USE: ■ Domestic 0 Industrial 0 Municipal Well Street Address Grapeview Loop Rd.
V1 0 DeWater 0 Irrigation 0 Test Well 0 Other City Grapeview County Mason
TYPE OF WORK: Owner's number dwell(if more that one) Location Sb/4-l/4 421/4 Sec Z Two 21 R 1 EWM 0
g 0• New well 0 Reeomd'aioaed Msrltod:0 Dag ❑ Bored ❑ Driven (s,t,r SOD REQUIRED) WOr i♦
❑ Cable ❑ Rotary ❑ lewd
DIMENSIONS: Diameter of well 6 inches,drilled 14. ft LULoag
Depth of completed well_ft Let Deg Let Min ec
CONSTRUCTION DETAILS Long Deg Lotig MiNSec
Casing / Welded ¢ Di,® from +2 ft.b 142 ft Tax par' No.(Required).121Q]3250300 'm '
hutaned: ❑ Liner installed " Diam.from ft to ft
0 Threaded " Diam.From ft to ft - .
4.2 Pertoratiau: ❑ Yet ■No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type perforator for used Formation:Describe by color,character,size of rnateriakand structure,
and the kind and nature of the material In each stratum penetrated,with at
aSIZE of pats pia by in.and no.of profs from;ft.toft least one entry for each change of information (USE A•i ITIONAL
etC . Screen: ■ Yes ❑ No 0 K-Poe Location 140 SI{EETS IF NECESSARY) _
fr Manor ctwer's Name Machine Alloy Works MATERIAL FR• ' ` TO
Type stainless Model No. Topsoil 0 2
Diane s sloe arm n ?tom "2ft to N? ft Saturated grey and&gravel 2 55
12 Diem Slot sac from ft to ft.Gravel/Filter
blue silts&clay S5 12Gravel/Filter ❑ 7
er packed: Yes d No Sias gravel/sand grey sand&gravel 1 27- 147
eti Maieriah placed from ft to ft
aSurface Sul I Yes ❑ No To what depth? 37 ft. "'
a Material used in seal
Did ay strata contain uausable water? 0 Yes III No e
Type of Weil Depth anima ,
Method of sealing strut off
PUMP: Muwfachcer's Name GOLlda
Type:sub H.P. 3/4 _ . . . a.
G WATER LEVELS: land-surface elevation above mean sea krel ft , J.
et Static level 50 ft below top of well Date t
Artesian pressure lbs.pet square inch Dare
Zia Artesian water it controlled by • (ap,valve,etc.)
WELL TESTS: Onwdown is amount water level is lowered below static level '
Woe a pump test made?❑ Yes MINo Um,by whom?
Yield: salhain.with ft drawdown after' lot.
Yield: gatimin.with^^R w d swdon after bra. �`I
Z - Yield: gatimin.with_ft.drawdown after hrs. RECEIVED
Recovery data(lime token as zero when pump turned oil(water tent tnrarandirom -
T top to wow level)
Time Watts!.ever! Time weer Level Tura wear Level MN( 232016
t WA State Daptrtnnen
Date��# a of Eca IogY (SWRQ)
15 Bailer tat,15 giVmin with ft.70dsswdown after I las. '
•W is;,..,Aittat galimin.with stem set at ft for hrs.
15 Artesian flow g.p.m. Date .
Temperature of water Was a chemical analysis made? ❑ Yes III No Start Date1/9/15 Completed Date 2/14/16
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with ail Wallington well
construction standards. Materials used and the information'reported above are tau to my best knowledge and belief.
®Driller 0 Engineer(jTrainee Name Ernsy Davit Drilling company Davis Dylan
Signature Address 340 NE Davis Farm Rd
DrillerCI
or trainee License No.3142 City,State,Zip Belfair,WA 98528
4? IF TRAINEE:Driller's License No: Contractor's
Driller's Signature: Registration No. DAVISDI1100A Date Feb 2114
ECY 050-1-20(Rev 02-2010) 46-41ndairling materials in a formatfor the vkaalty impaired call Ecology Water Resources Program
at 360-407-6872 Persons with Itatpafred hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 8774133-6341.
26276"'We've
Trees Ln NW
Ste.0 !' SPECTRA LabOratcories i Kitsap
Poulsbo,WA
98370 ...Where ezpersersce loaner
• (360)779.5141 COLUFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
•
12 c I Z Collected � r
Month Dry Veer fr :30 a PM '"w GJ C'
Type of Water System(check only one boor)
❑Group A 0 Group B '
Group A and Group B Systems-Provide from Water Faculties Inventory(WI):
ID#
System Name: r ( /v/ e Coc -e
Contact Person: ra • 1�?r^lf, f'jgy,r•-r
Day Phone: Cet Phone:(3la, per/ ..11.37.5
Email: Eve.Phone:
Send resift to f iintfdrnwr,address and bp cod.«.men above for electronic copy of results)
DLvslS..dp it;ry j- c 1-2,014-7‘1.
SAMPLE INFORMATION
Sample collected by(name):
Specific location where sample collected: I Special instructions or comments:
1,-,¢14 Iic- i
Type of Sample(check only one box)
1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(A/P)
Chlorinated:Yes D No❑ (froe distribution system after unsat routine)
Unsatisfactory
Residual:Total Free__ routine lab number
3.Ground Water Rule Source Sample ——— —— ——
ISI I I Unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered (A/P)
Chlorine Residual:Total Free__.__.
❑Assessment(A/P)
4.Surface or OWI Raw Source Water Sample(Enumeration) I S
❑ E.E.coil 0 Fecal Filtered Yes._._No
5.ffanpie Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colifoml Present and tisfactory
❑E.cofi present ❑E.coiabsent
Bacterial Density Results:Total Conform mpn/100ml Ecoti mpn/100mi.
Fecal Coliform_ cfu/100m1. HPC cfu/1ml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume 0 Damaged Container 0 _ ..............
D fp/rprq eoay ed
12-0 D Lab Reference Number
Receipt Temp C': Method Code:.alp, . T-COUNT/SM9222D
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Date / Date Out „ t/ ,n� r,. e,4. .copyingaae eear«ne,byb
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•
2196695 MASON CO WA
05/03/2023 10.44 RM NOTCE
DAVITS DRILLING' *18665p02 tRec pFee IIIIII 204.50 Pages. 2
Return To 1111111111JNIUIIIJ 1iftIII 1liN�1111iII19lUIIIJillIIII
Dy
3 q o N - 1)av► c Trios-e-et
Bdfair. t JF 13 SZ�
Grantor(s): (1) , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) 3 OF Lt-S i 0- z_ AF.if(`), 10630 P/N N W SW
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 1 Z. ! n L - 3 - S 3 Q O
5o .7 _ 2 -
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 ( U 1 - 3 2 - �, (' 3 O O
Tax Parcel: (Connection 2) 2 1 0 , 7 - 3 2 - C O I O
The system owner is responsible for keeping this system in compliance.
The name of the water system is: GS
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.
Dated on this 2, day of A ., , 2023.
Signature of Gr tor(s):
(1) , (2)
Page 1 of 2
•
State of Washington
County ofi►4eson KA..ser )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 2t day of Aria , 20 23, ,
C6r/o5 ESifaek 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.
NOTARY PUBLIC 2/�fl/`
STATE OF WASHINGTON Notary Public in and for the State of Washington,
CHRISTATHARP residing at 3371- l2t44td Sf
MY COMMISSION EXPIRES My commission expires: Os Jii/zii''r
JANUARY 12,2027
COMMISSION NO.23003216
Page 2 of 2
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Mason County WA GIS Web Map
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0 0.01 0.03 0.05 mi
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0 0.02 0.04 0.08 km
0 No Filled
• Site Address (Zoom in to 1:3,000)
Source Esri,Maxar,Earthstar Geographies,and t ie G ,User Community
El Tax Parcels (Zoom in to 1:30,000)
Mason County WA GIS Web Map Application
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