HomeMy WebLinkAboutWEL2023-00025 - WEL Application, Design, Letter - 5/3/2023 MASONCOUNTY 415 N 6TH STREET, LTON, , E, E 400 98584 SHELTON: SHE T 967XT
111 SHE BELFAIR:360-275-4467, EXT 400
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
r
Illillial
40.Ati4•N„ivy 5
`` \ MASON COUNTY Date Receved: J 5 I
„9-- ,
'3 .. � COMMUNITY SERVICES AmountRec : R vedB
t+ • ��-�
ry .-HIP(3�'�. Building Planning Environmental Health Community Health
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L , .[)),,3 - d 0 Oa S
Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE (� 2S—
C LS ci L in L. 1 (L ?) 31 L 9
MAILING ADDRESS-STREET,CITY,STATE,ZIP
116s? 5c 67racrk Rd ai4 c iwli .g057
SITE ADDRESS-STREET,CITY,STATE,ZIP
c.4'1 vn(.t t i't. ( 0\) - O( CIra- ;1/4/,1'W 18 VICi
PRIMARY PARCEL NUMBER(WELL SITE)
l7i0 -132-ct3cel
SECONDARY PARCEL NUMBER(IF APPLICABLE)
1 21 01 3 2-To I 0 0
WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE
0 New ,Existing p1 Well 0 Spring • CS 1 S, 61-
PROPOSED WATER SYSTEM NAME(REQUIRED)
PROJECT DESCRIPTION
1 - t'h.1 w211
DIRECTIONS VZ Y
TO SITE/COt{DrTIONuC ' `.C_ CPO T V _J '11 — n rk 1-t-H- 1 a I vvt (A+
k
Site Plan: (may also be attached) _
(property boundaries,structures,well site w1100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
12101 2,2 %o iCU
____ er-oeer--hd .# 2_ ,
\,�ALL ��
-
II-In :1' S'03C
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)
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: _75-i 10 Stgel bid 5,,te, y F 7- -(., S0 yu/ dri' auiPi eze/Coptc4r
-7 -r-kok) 5here
YES NO NA - -rig' lc 5 �5'� 'vie_S.7'�o food
0 ❑ ❑ 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 riv te, County or State.
What is distance to ROW? I3
i] 0 ❑ Does the ground slope away from thet water source site? (show slope on plot plan)
^
1 ❑ Is the well cap satisfactory? 4(1 ` e MOVY105 /V( CA`-'. (6Ke- �---------.,N
❑ ❑ Screened and vented?
0 The well casing extends Z I U
above level ground/concrete slab? (cir a one)
txt ❑ ❑ Is there evidence of a surface seal? l..p f 1i1,.?Z it/6'35
® ❑ ❑ Does the seal appear adequate? Loll: -IZ Z, $6'I 113y
/❑` F] ❑ Is a variance necessary for well site approval? YGy , ET H Ohs'"
Comments pfyi -j '( 610U11 / 6M's- . cif/ ►'herd Ali 1 o se.
---� 6(91z02I.. Y0(15' - tiee.( f Writ nlyueej.
ikrfPass 0 Fail Inspector 0_� Date 5//6/7O1 Z�
Review Step 2: Two-Party Review:
Ypr NO NA
0 0 Water Well Report with adequate pump test on file? _
If NO,date of Capacity Test Driller GPM
0 ❑ Received Satisfactory Bacteriological Analysis? Date of test 9t Zc(zGaj
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z. g go;
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments 67 y zzo,Z3, 4C6Yel fry1 of c(ea 1c/1).
Approved ❑ Denied Reviewer • Date 6(5/N23
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", 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 WELL REPORT CURRENT
Original a I"copy—ecology,r'copy—owner,Y'copy—drake. Notice of Intent No. WE22780
oVYrrmam or
ECOLOGYOG Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. B
® C011St(UCtIOn 111075
Water Right Permit No.
mom
e■ 0 Decommission ORIGINAL INSTALLATION Property Owner Name Shawn glade
'Notice of Intent Number
PROPOSED USE: U Domestic 0 Industrial ❑ Municipal Well Street Address Grapeview Loop Rd.
VI 0 Dewater 0 Irription CI Test Well ❑ other City Grapeview County Mason
TYPE OF WORK: Owner's number of well(if more than oat) Location SM1/4-U4 SJ114 Sec j Twn 21 R 1 EWM 0
g I.New ❑ Reconditioned Method:0 Gable 0 Rotary Bonn 0 Jetted (a,t,r Still REQUIRED) Or
Deepened WWM •
DIMENSIONS: Diameter of well 6 inches.drilled 147 A. •
IatJLOag
g . Depth of completed well_t Lat Deg Lai Min)*CONSTRUCTION DETAILS Long Deg Lotig Min/Sec
Canal III W " Diana.from +2 Rao 1E_t Tax parcel No.(Required)MI03250300 : '
[walled: ❑ Liar iwtanee - Diem from t.to, A.
0'?headed " Diem.From t.to a
Parterseaaa ❑ Yes U No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of tun acter,
used Formation:Describe by color,char ,size of materiaband structure,
C ' and the kind and nature of the material in each stratum penetrated,with at
a SIZE of pars in by in.and no.of PuB_ from t
---.to�_tt least one entry for each change of information (USE A a}ITIONAL
. Berner: ■ Yes lj No 0 K-Pere Location 140' SHEETS IF NECESMATL L FRa r TO
Maatrbctwec's Name Machine Alloy Works
Type stainless Model No. Topsoil 0 2
Diem s Slot size 7D ai from lu a to u, R •Saturated fey sand&gravel 2 SS
MI6 scs tom R to . Wet blue silts&clay SS 127
�, G el/FWsr peeked: 0 Yea III No Sia o(trawUsaad greysand&gravel i;27 147
t0 Materials placed from t.to R 1,.
tM Serrate Seat: IN Yes 0 No To whet depth? n t
CS Material used in seal armor
Did any strata contain unusable water? 0 Yes isNo e
Type of water? Depth Murata
Method of sealing strata off . ._ ._-- —
PUMP: Manufacturer's Name Goulds
Type:sob H P. 3/4 • r.
cr WATER LEVELS: Land-surface elevation above man sea level tt
elil Static level 50 R below top of well late
ti.. Attaian pressure lbs.pa square inch Date
(9 Artesia water ii controlled M (ap.valve.etc.)
WELL TESTS: orawdowa is amount water level is lowered below natao level ,
Was a Pump tat made?0 Yes • No If yes,by whom?
Yield: gat/min.with A.drawdown after has.0r
Yield: tpthnne with—a drswdown ate hrs. RED ■
tZ - Yield: gaVmin.with ft.dmwdown after bus.
• VED
Recovery dam(H e..token or corn when pump tamed offl(water Ind memaartd from
well sop to wawa level) Q�A�6
43 Time Water level Time Water Level Time Winer level - u Cl;IX 232016
0
WA Sta is DGpnrtl+r1eh
t of Ecology (SWRO)
Dare of tea a
15 Bailer teal 15 gat/min.with 70 A.drawdown alto I as.
{/I �'Aistat gaihnin.with stem set at tt for hrs.
15 Artesian flow yp.m. Date •
Imminent of water Was a chemical analysis made? 0 Yes U No Start Date1/9/15 Completed Date 2/14/16
WELL CONSTRUCTION CERTIFICATION: [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 bat knowledge and belief.
®Driller 0 Engineer°Trainee Name En*Davis Drilling Company Davis Drilling
Drilla/EngineerTrainee S Address 340 NE Davis Farm Rd
Drilla or trainee License No.3142 City,State,Zip Relish.,WA 98528
IF TRAINEE:Driller's License No: Contractor's
a Registration No. DAVISDI1100A Date Feb 2016
a Driller':Signature:
ECY 050.1-20(Rev 07-2010) A1a=artncludbtl material:in a fon,rat for the ttfsrldly bspilre4 till Ecology Wale Resnwea Program
w 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may can TTY at 877-833-6341.
1
26276 Twelve 1
Trees Ln NW
Ste.0 SPECTRA Laboratories Kitsap
Poulsbo.WA
...Where experience mnnera
9R3
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tine Sample County
DIi L i 2 j Collected 6 NA �f
Mons Dry .4y year :.76 o pM '".zJa')
Type of Water System(check only one box)
❑Group A ❑Group B Other_
—
Group A and Group B Systems-Provide from Water Fealties Inventory(WFI):
ID#
System Name: , r F `/Gr e
Contact Person: A. ,7Y �{�r"Is„ �'Jg4,r'-�
Day Phone: Cell Phone:( 3(ar) die/ -t1 jn
Email: Eve.Phone:
Send results to:(Print Minima,edtrets and zip code or well above for afedronk copy cc mutts)
SAMPLE INFORMATION
Sample collected by(name):
Specific location where sample collected: Special instructions or comments:
¢ti hci
Type of Sample(check only one box)
1.❑Routine Distribution Sample(A!P) 2.❑Repeat Sample(AlP)
Chlorinated:Yes ❑ No 0 prom distribution system after unsal.routine)
Unsatisfactory routine lab number.
i Chlorine Residual:Total Free
- 3.Ground Water Rule Source Sample ——— — ——
S I L I Unsatisfactory routine collect date:
1 I
Chlorinated Yes No_ ._..
0 Trggered (AIP)
0 Assessment(A/P} Chlorine Residual:Total Free______
4.Surface or GWI Raw Source Water Sample(Enumeration) I s
- ❑ E.colt 0 Fecal Faxed Yea_No--
5.ILy sample Cotected tor Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and isfactory
❑E.co6 present 0 E.coli absent
Bacterial Density Results.Total Coiform mpn/100m1.E.co6 mpn/100m1.
Fecal Coliform_ cfu/100m1. HPC_ cfullml.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container ❑
iris R at: Lab Reference Number
1 1DTIT _
lIoD 30`l `aZ
Recerpl Temp C': Method Code:
T•COUNT/SM9222D
Dahl Date Out nu math risiore1m .ou»ae.w�nw«yynb
� /2.5 1.3 7 t/ e6"d'd7 tin i mpyMgoeedaeueaw tan by he
'^yl L)+�Jf/• r JYlrii iirid.e neper+evwMru¢ru Myou tie roarvee srn npat�
erw,pYw noOr M.eroa hiaaa)abb'tl M�T!P3N1.rd
DOH
�L.ab-Smprha1/]] a•TM/r.anDOIPen9N
01Y• �V 1 O Z 'Mae rMla Rim oaf bee dorm Med.r M.nipN(a)M
• L --- b U.tam(coo WprMVen.n.rpvm.r by SpeRa Litori�ieeary Thi dolma and rot be rdroductd eaa
DOH Farm 1331.9rB(el.edra arel7)
2196695 MASON CO WA
05/03/2023 10:44 AM NOTCE
DAVIS DRILLING 1186502 Rec Fee. 204.50 Pages: 2
Return To 1 IIIIIII IIIIII IJ I111111111111111111111 P1 BhIII P r l�lID IIll
ta1/4/;5 DriM!!
3q0 N - �a� STZ+r�
Beif;r. titlfr 1'aS 756
Grantor(s): (1) , (2)
Grantee(s): (1)PUBLIC Legal Description (1) Lek 3 OF L+-S 44 0-02. I PF4f 1' 1 e 3o PTA! Cf N IU SW
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 1 1 _ C) 7 - 3 - S j 3 a O
Sal - ( 2- 1 - 1
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 1 U 1 - 2 - � O 3 C 0
Tax Parcel: (Connection 2) t. 2 1 0 -7 - 3 2 - 0 I 0
The system owner is responsible for keeping this system in compliance.
The name of the water system is: r -i-vrAkak
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 j--\ . , 20 Z3.
Signature of Gr torts):
(1) , (2)
Page 1 of 2
f
State of Washington
County of•Meeoe Ic ''
I, the undersigned, a Notary Public in and for the above named County and State,do hereby
certify that on this 2t day of ,4 .i' , 20 23 ,
Cu-/aS E5f/g.L 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 (Yd.*
STATE OF WASHINGTON Notary Public in and for the State of Washington,
CHRISTATHARP residing at 33 i' 46/444 gJ st
MY COMMISSION EOI'IHES My commission expires: ot/0424t}
JANUARY12,2027
COMMISSION NO.23003216
Page 2 of 2
Mason County WA GIS Web Map
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5/3/2023, 9:37:23 AM 1:1,533
0 0.01 0.03 0.05 mi
Count Boundary + }
Y o 0.02 0.04 o.os km
❑ No Filled
Site Address (Zoom in to 1:3,000)
Source:Esri.Maxar,Earthstar Geographies,and L ie G ;User Community
Tax Parcels (Zoom in to 1:30,000)
Mason County�JA GIS Web Map Application
Maxar,Microsoft I