HomeMy WebLinkAboutWEL2023-00015 - WEL Application, Design, Letter - 3/28/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360427-9670,EXT 400
BELFAIR: 360-275-4467,EXT 400
F." Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
Stark, Katy
3724 Simmons Heights Lane SW
Tumwater, WA 98513
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00015
148 SE Mable Taylor Ln
319101400130
The 2-party water system, Stark 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
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ii MASON COUNTY c 2D J V
COMMUNITY SERVICES E.........._____ „__ ____„.
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TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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riwrAmm- - , ,..., . 'Ward--
O New U'1:nisttti Well 0 minx _ __ _
'easpzelk sonar NAAS waft* . -
u �kA)etAdS r PL.I.
lilts Plan: (may also be attached) and )
(property boundaries,structures,well sae w4t ar drt
radius, Newsy*,roads,septic/saw 5ceL CX.
? Cfk(-3M-6(
Submittals Checklist: (these additional items will be required for approval)
'Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
(g'yVell Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well Is not yet drilled)
(a' otice to Future Property Owners recording(record with Mason Co,Auditor,supply copy of recorded document)
BSeptic Records(additional locating requirements may apply if there Is a lack of septic records on file)
This form may be scanned and avaliabla for public view on the Mason County Web sits. Revised: 10J13/2021
Page 1 of 2
Stan Use Ordy .- ------- ---�--
Review*Sep 1: Well Vas leepeolieni k.
/
YES NO NA
03 0 0 Evdsnoa cif adaWtp eau ass of contamination w1Wh 100 toot radius of water*autos?
(drairdlebr,:erica.bourns. indicate dislsnce on plot per')
10 0 0 Are them reads within to 1 tore_r of vow sauce?If ob.Is road privets Carly o Slate.
Whet Is distance to ROW? "
jiff 0 0 Does the f round slope away front tree aide*owes site?(show slope on plot pion)
0 ❑ is the wee cap s ties olory?
0 0 Screened and vented? I i
❑ The VAMP awing extends I S .bore level t oextd l also?(circle one)
(rj 0 0 �"Mince of•'tote:*sett? `� �; , 7. I N 90 1 D
pi 0 0 seal appear adequate?
❑ tji ❑ is a variance neoessery for well ale approval? Lc") % - 1 Z3.03 S 77 6 7
gut-Sg;
Pass ❑ Fail Inspector7,27-------- Data 672/ ZQ Z
Review Step 2: Two-Party Review:
RS NO NA
0 0 Wave Well Report with adequate pump test on file? I,
If NO.date of Capacity Test Ki'5/Z 0 Z ( Die* (9 (/l GPM tf5
0 0 0 Received Satisfactory Bectenotogl s1 Analysis? Dale of test 3l97 Z�/Z 3
0 0 Received Signed,Notarized,and Recorded Notice? AFN ?(C(G z 13
pi0 0 SYatem appears adequate to serve 2 single-farnly residences based on Information provided?
Comments
it Approved 0 Denied Reviewer A9 Date 6 ' [ Z ?J
Findings In this review reflect ohser►ed rnnditions 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 tvm-pan process.
All proposed connections to new wells are subject to water adequacy requirements at time of building penrrh per MCC 6.68.
Water stage restrictions and additionl fees may apply to all new wells drilled after January 19".2018 per ESSB 6091.
T1i tune may be scanned and available for pubik view on the Mahon County Web sibs. Revised: 10113t2021
Page 2a2
Thurston County Environmental Health
2000 Lakeridge Dr.SW 4 Olympia,WA 98502
360 867-2631
i THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected V�(�aSo
Month Day Year __i IPM
Type of Water System(check only one box) ❑ Private Household
❑Group A 0 Group B ,la—Other—A LX)
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): UU
ID#
System Name:
Contact Person: y4 Sex{''
Day Phone:360)- WO 37 40 1 Cell Phone:( )
E-mail:yNA5r} r 'en'`m fj (01\Eve.Phone:( )
Send results to:(Print full name,address a`ndzip code or email address)
i i A!A �C -ll rnr, r 01 SAMPLE INFORMATION
Sample collected by(name): )4N sw.K
Specific location or address where sa collected: Special instructions or comments:
\� s E roc( n,
.1\s&tin �, � 1� i t)C b`I
Type of Sample(must check only one box of#1 through#4 listed below)
1. Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free_ Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli—GWR(NP)
❑Fecal—Surface,GM,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(NP) Unsatisfactory routine collect date:
❑Other
S
4.0 Sample Collected for Information Only —
Investigative Construction/Repairs. Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent o liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coli /100m1.
Fecal Coliform /100m1 • Enterococci /100 ml.
Method Code:KSM 9223E :ISM 9222D Date and Time Receive\
❑SM 92158 ❑Enterole* —S•S- Z3
Date and Time Analyzed: 3- D- Z� Date Reporter 'jle,,pc
Sample Number(DOH number pb s five digits) Lab Use Only:
8
OH Form#331-319(revised 01/16)
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WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE43278
ECOLOGY
Unique Ecology Well ID Tag No. BNK 883
Type of Work: State of Washington
17 Construction Site Well Name(if more than one well):
0 Decommission 1=> Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: 0 Domestic 0 Industrial 0 Municipal Property Owner Name Michael&Katy Stark
0 Dcwatering 0 Irrigation 0 Test Well 0 Other Well Street Address 148 SE Mable Taylor Ln
Construction Type: Method: City Shelton County Mason
El New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool
❑Deepening 0 Other 0 Dug El Air- 0 Mud-Rotary Tax Parcel No. 31910-14-00130
Dimensions: Diameter of boring 6 in.,to 120 ft. Was a variance approved for this well? ❑Yes I]No
Depth of completed well 119 ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
p I 0 6 in. +1 119 .25 in. O I 0 0 I ❑ Location(see instructions on page 2): (l WWM or 0 EWM
O I 0 in. — th• ❑ I 0 0 I 0 SE %.-%of the NW /;Section 10 Township 19N Range 03
❑ 1 0 in. — — in. ❑ I 0 0 I 0
❑ 1 0 in. in. ❑ 1 ❑ ❑ 1 ❑
Latitude(Example:47.12345) 47.14911
—
Longitude(Example:-120.12345) -123.03587
Perforations: 0 Yes RI No Type of perforator used Driller's Log/Construction or Decommission Procedure
No.of perforations_ Size of perforations by Formation:Describe by color,character,size of material and structure,and the kind and
Perforated from ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of
Screens: ❑Yes O No ❑K-Packer b Depth_8. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No.
Diameter_ in. Slot size in.from ft.to ft. Clay,Silt,brown/soft 0 3
Diameter in. Slot size in.from ft.to ft. Sand,gravel,silt,brown/soft 3 15
Sand,gravel,silt,some clay,gray/hard 15 26
Sand/Filter pack:0 Yes 0 No Size of pack material_in. Sand,gravel,silt,brown/hard 26 39
Materials placed from R to_ft.
Clay,some gravel,gray/hard 39 55
Surface Seal: ❑Yes O No To what depth?_ft. Sand,silt,some gravel,gray/soft 55 66
Material used in seal Clay,gray/hard 66 70
Did any strata contain unusable water? ❑Yes 0 No
Type of water? Depth of strata Sand,gravel,silt,gray/soft 70 112
Method of sealing strata off Sand,gravel,silt,gray/soft,wb 112 120
Pump: Manufacturer's Name N/A Type:
H.P. Pump intake depth:_ft. Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level ft.
Stick-up of top of well casing+1 ft.above ground surface
Static water level 77 ft.below top of well casing Date 8/5/2021
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? IN No 0 Yes b by whom?
Yield_gpm with_ft.drawdown after_hrs.
Yield_gpm with_ft.drawdown after_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 ft drawdown after_hrs.
Air test 45 gpm with stem set at 117 ft.for 1 hrs. Date 8/5/2021
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes Cl No Start Date 8/5/2021 Completed Date 8/5/2021
WELL CONSTRUCTION CERTIFICATION: I 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.
• 17 Driller 0 Trainee 0 PE-Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature ( ( .,. Address 1162 NW State Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 8/5/2021
ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at
360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call
877-833-6341.
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2196213 MASON CO IAA
04/21/7023 10 48 AM NOTCE
MIC1 EL STARK 118813B R.o Fee $204 50 Ps es 2
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Return To
01-chi 4 Vc,1L r i ll c,.S I
We S b "Tc1kuktor 1.(?1.-1rz
Grantor(s): (1) m10\ Sbi(t , (2) 02 f 1 Ir\CSK
Grantee(s): (1) PUBLIC
(`
Legal Description (1) t t 9 drc"
fr-)
(Abbreviat form:i.e. lot bloc/k,, plat or section, to ship, range)
Assessors Tax Parcel: (1) 3 \ D - `'t -o O , v
5 lo 7 i 9 g 3
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)3 1 C\ 1 0 - 1 - U C) l 3 CD
Tax Parcel: (Connection 2) -
The ----
The system owner is responsible for keeping this system in compliance.
The name of the water system is: �`= 1
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 7- tri day of (f\&ecr_v� , 20 _3•
Signature of Grantor(s):
(2)
Page 1 of 2
State of Washington )
County of Mason
I, the undersigned, a N?tary Public in and for the above named County and State, do hereby
certify that on this 2 L day of rz( c 1-. , 20 z 3 ,
b6c tik&( e „d personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (s e)-(t ey) signe it.
GIVEN under my hand and official seal the day and ye above written.
SARA GODAT Notary Pub' ' e State of Washington,
NOTARY PUBLIC#21022765 's
STATE OF WASHINGTON % residing at
% COMMISSION EXPIRES My commission expir s: Z I z 2-s
JUNE 21, 2025
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