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HomeMy WebLinkAboutWAI2023-00051 - WAI Health Waiver - 5/23/2023 t. 415 N.6`h STREET,SHELTON WA 98584 MASON COUNTY SHELTON:36C-427-9670,ext 400 COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400 ELMA: 360-482-5269,ext.400 Building,Planning,Environmental Health,Community Health FAX:360-427-7798 Ii ati for Waiver or Appeal Amount Paid: Y Y Receipt Number: a-3 — p p WAI bI-7< OCXDSC J�� MAY 23 2023 Instructions: I- � 1. Complete Parts 1 and 2. No determination can be made until these parts are fu v completed. 2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1. Applicant & Parcel Information Name of Applicant Terence & Ingrid Clancy Telephone (425) 444-4490 Mailing Address 2638 169th Ave SE City Bellevue, State WA Zip 98008 Parcel No. 2 2 1 3 3 -_ 5 0 -- 0 0 0 0 3 Site Address 401 E Osprey Ln, Shelton, WA 98584 PICKERNG PASSAGE F 6 G TRACTS(UNRECORDED)TR Id(N]5'o'Lot 6 6 T'.(T.648-3 a f N]C io9el+er+iu+TR 13 OF G L.IS f 5'of Te 5130 0f G.L..S.TA.63A+A(OF SEC 11 Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements ❑ Onsite: Class B Waiver ❑ Group B Water System Regulations ❑ Onsite: Class C Waiver ❑ Water Adequacy Requirements Onsite: Location, WAC246-272A-0210 ❑ Building Permit: EH Review Policies ❑ Onsite: Holding Tank, WAC246-272A- ❑ Appeal:Enforcement Timelines 0240 0 Appeal:Departmental Determinations ❑ Onsite: Contractor Certification 0 Other Requirements Description of Waiver/Appeal (include justification, additional material may be attached.): Waiver Sought: Reduce horizontal separation between primary and reserve drainfields and neighbor's well from 100'to 75'. Mitigation Measures: Septic system proposed is an OSCAR XO2, which meets Treatment Level A without disinfection. General direction of slope is away from the welIKVea well logs are attached and neighbor has been notified via certified mail. Documents are attached. A n Date: 5-15-23 pP A licant Signature: '�`�!`- 6A ONN-)3 , _ �,y . �� Q — Revised 8 13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 � I PART 3: Public Health Evaluation (Staff Use Only) tiCa l 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal X Waiver None required Class A Class B Class C 2. Identification of Specific Code/ Standard! Determination (include date of determination or latest Code/ Standard revision): U/ 9C: 2`f 6•Z f'Z$'GZ 2 0 3. Na/pre,of Appeal: kcdvice -thc Rio+%zeo k f $e '91/c beNee4 cm 055 c rpa/so/ st,51e n and . I`4`J/( ''cvG/ weA/ -row 00 td l S' 4. Hearing Official: ❑ Board of Health 0 Health Officer 0 Pollution Control hearing Board 0 Public Health Director 0 Certified Contractor Review Board le Environmental Health Manage 5. Mitigating Factors: TN? 050/4 XC)Z ,542f-Lsy4r , tieI199 ivis/g/led- /V 0l ' tvel6 w,Y6, /00 ' or eira,r7 t/e/cr T&/ri'a 5/g,6 QVar �rn w // of d the- cl1Gi J%b/c/ r3• dovo q/kel(e2f 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: Date: •776/QrJ 3 PART 4: Determination of the Hearing Official The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. This decision is based on the following findings and conditions: 0 The hearing official has determined that approval of this request could potentially adversely effect public health and is hereby denied. This decision is based on the following findings and conditions: Health Official Signature: 'CV Date: _ 2 C'/1) I:‘2cised 8/13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 2of2 Arrow Septic Designs 171 E. Vuecrest Dr. Union, WA 98592 Cheryl Raff 116 Willow Way Chehalis,WA 98532 May 10, 2023 RE: Terence&Ingrid Clancy New Septic with Well Waiver-Parcel #22133-50-00003 Dear Cheryl, This letter is to inform you that we are currently working on a septic design on the property next door to yours at for Terence&Ingrid Clancy located at 401 E Osprey Ln, Shelton,WA 98584. The proposed waiver is to place the drainfield as close as 75 feet from your well on Parcel#22127-33- 00010 located at 196 E Vineyard Dr, Shelton, WA 98584. The standard setback is 100 feet,but the state and local health code allows us to lessen this distance down to 75 feet. To mitigate the setback reduction on this project,the septic system proposed is an OSCAR X02 low profile mound septic system with timed-dosing. Also,the general direction of slope/drainage in the proposed drainfield area is toward Pickering Passage and not toward your well. The drainfield meets the 100 foot standard setback for Pickering Passage and we are not asking for a reduction there. The proposed system meets treatment level A without disinfection, a higher standard than the treatment level B required. You do not need to respond to this letter, it is for notification only,but you can feel free to contact the local Health Department or myself with any questions. The Mason County Health Department regulator contact information is as follows: Mason County Department of Health Services 415 N 6th St Shelton,WA 98584 (360)427-9670 ext. 400 If you need further information,please contact my office at paulaj@hctc.com or(360) 898-2255. Sincerely, U.S. Postal Service`"' CERTIFIED MAIL® RECEIPT co Domestic Mail Only '. For delivery information,visit our website 21 www.usps.c rr' Paula J. Johnson ;cor'`ed MallFee $4.1`t 0460 4 Licensed Onsite Wastewater Treatment System Designer r $ $3.35. 44 _> Extra Services R,Fees(check box,a Sa fee ti:Inti 0 Return Receipt?ardocpY) �rx` 0 ❑Return Receipt ieteotroruc S $i.no POsiiria 1< // 1� 0 Certified Ma.,Restricted Denver/ $ $C['Xi gele a 0Adussigne-,t-eReau:red S0. 0 �. fGAdult SiCsatUe Res-r:cted'e very Postage $ia.63 s 1 fU Total Postage and Fees y�.1J Sent To Dt.treet and Apt.N fox No. MA,A, 4-) \-lava a3 Q� Q 5—(O - Z 3 City'StstC A•rd r try 4$S 3 Z PS Form 3800 A•ril 2015 PSN 7530�02.000-90»% See Reverse for Instructio. WATER WELL REPORT CURRENT . orkiaa&I"copy—Ecotoy,2idupy—oweer',3`r copy—driller Notice of Intent No.WE22045 . t�pmvin not Uni ue Ecolo Well ID Tag No.BAH885 .IpC«2L CoOStruction/Recalnmission("x"in circle) 9 ' Co1>struCti00 Water Right Permit No. DecomtniSeDtRIGJ .�I INSTALLATION Property Owner Name Michael Homer • Notice of Intent Number QED ice:. is Domestic ❑ Industrial 0 Menicipal Well Street Address_ 411 E.Osprey Lane a Irrigation prat well 0 Other City Shelton County Mason TYPE OF WORK: Owner's number of well(if more than one) _ Location NE 1/4 1/4 NE 1;4 Sec 6_3 Twn 21 N R 2W EWM D 3 Nl ❑ Reconditioned Mrthod:❑❑ Cable ® Bored 0 Jetted (s,t,r Still REQUIRED) o' www :.DimeNSIONIk:pipletteter of we116 inches.drilled 139 ft. El 0dilei of completed well 135ft. LatlLong Lat Deg 47 Lat Min/Sec 16'18"N CciNSTR uCT toN DETAILS :Casing El Welded 6" Dian,.from +1.5 ft.to 132 ft. Long Deg 122 Long Min/Sec 55'56"W '"tewtted: 0 Linerinstalled Dram.from R to R. Tax Parcel No.(Required)221335000004 ID lIt lded " Diarn.From ft.to R. pp a �; ❑." 1n Na Type of perforator used CONSTRUCTION OR DECOMMISSION PROCEDUREur Formation:Describe by color,character,size of material and structure,and the kind and m.and no.ofperfs from ft.to ft. nature of the material in each stratum penetrated,with at least one entry for each change SIZE of perfs in.by__ of information. (USE ADDITIONAL SHEETS IF NECESSARY.) C Screens: El Yes 0 No El K-Pac Location 129 MATERIAL FROM TO visas ManofactmersName Alloy Machine Works Brown silty sand,gravel, 0 Type Stakllias.Siotted Model No. cobbles 4 Diana 5"SlrtRili;O14from 130 ft to 135 ft. Brown fine sand,gravel, 4 D By glut size from ft.toft. loose 17 Graw:unites.packed: 0 Yes ❑ No Size of gravel sand Brown silt bound sand,gravel 17 laMaterials placed from fi.to ft. tight 19 ea Saif ceSeal: ® Yes 0 No To what depth?19R. Brown medium sand,gravel, 19 } Mateiiiinsed in seal Bentonite ChiPs loose 72 i'� Did any strata contain unusabkwater? O Yes ® No Brown medium sand,gravel, 72 Type of water? Depth of strata loose,wet 81 Sit bledtodofseating strata off Gray clay bound sand,gravel 81 83 Gray silty clay with gravel _83 90 per!1Naretrfactmer'sNamc Gray silt,some gravel 90 94 I Type: H.P. Blanc pea gravel with gray a. 106 94 VVA7 tR L ►Jits: land surface elevation above mean sea level 162 R. silt,wet Static Ieiltw below top of well Date 10/13/2015 Gray silty Gay 106 116 Artesian pr�ute lbs.per square inch Date ell Black medium sand,gravel, 116 Artesian water is controlkd by (cap,valve,etc.) loose,water 139 WELL that•Si Drawdown is amount water level is lowered below static levet Wfaapaap test made? 0 Yes El No If yes,by whom? YiCI&.... gal/min.with_ft.drawdown after hrs. r.,`�j����� Yield: gal./min.with�ft.drawdown after hrs `L" L Yield: rml lmin.with_@-drwdown after hrs. I Recovery data(lime taken as zero when pump turned oft)(water level measured from I to J q wet!top to water level) t'LJ! i B'101I' Time Water Level Time Water Level Time Water level WA State t of_Pc o1 �epci Ment Date oFteut 09Y (SAAR()) 42 Bailer test gal./min.with ft.drwdown after hrs 15 Airtest 16alJnlin.with stem set at 125ft.for 1 hrs. Artesian flow a_p.m. Date I Start Date 10/13/2015 _ Completed Date 10/�3/2Q15 Ternperatare: ja�l4ra�L Was a comical analysis made? 0 Yes ® No 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 info 'on reported above arc true to my best knowledge and belief. Com v Arcadia Drilling Inc. Address Po Box1790 Driller r l EnPineer Trainee NaName(r rim)1 P • Driller/Engineerarainee Signature 'Baez or trainee License No.2874 Drilling City,State,Zip Shelton Wa, 98584 41,1 IF TRAINEE:Drller's License No: Contractor's Driller's Signature: Registration No. ARC DI098K.1 , Date 10/13/2015 EC1E1150-I 20(Rev 02/10) If you need this document in an alternate format.please call the Water Resources Program at 360407-6872. Persons with hearing loss can call 771 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. • t..'Z.k—: .i V L...1..• DEPARTMENT OF ''lt WATER WELL REPORT DEPART Notice of Intent No. WE401473 ( ; ` e ECOLOGY Unique Ecology Well ID Tag No. AA0078 _i_ I"`I ., .'`~` Type of Work: state of Washington .. ElConstruction Site Well Name(if more than one well): ..,..„ . ID Decommission = Original installation N0i Ne, Water Right Permit/Ccrtificatc No. Proposed Use: tJDnmestic . 0 Industrial ❑Muuicipat Property Owner Name Carole Flynn p pcwatcring t7'fii ttion 0 Test Well ❑Other Well Street Address 630 EStrong Rd C ,lfy.pr: Method: City Shelton County Mason 0) CI Alteration ❑Driven 0 Jetted Cable Tool 0)Dcepeain5 ❑Other ❑Dug O Air- U Mud•Rotaty Tax Parcel No. 2 21 28-44-90051 Dimensions: Diameter of boxing 6 in.,to 60 ft. - Was a variance approved for this well? ❑Yes G No Depth ofcompitted well 204 R. It ycs,what was the variance for? Consamct(tNi°AetdDs: malt. Cash*i ger7Dfameter From To Thickne` Steel PVC Welded Thread C3 1 0 8 in. 140 204 .025 I 0 t) ( ❑ Location(see instructions on page 2): 1l WWM or❑E\VM 0 I 0 in. in. I ❑ ❑ ❑ _SE Vs-Vs of the SE %Section 28 Township 21N Range 2W ❑ I ❑ in. — I C ❑ I ❑ i ❑ I ❑ in. n.. 0\ ❑ ❑ I ❑ Latitude(Example:47.12345) _____:, Longitude(Example:-120.12345) L Perforations: El Yes 1 No Type ofpet-fa-ator used `�o Driller's Log/Construction or Decommission Procedure n ea No.of perforations Sim of perforations 12 by irk. Formation Describe by color,character,size of material and struxme.and the kind and L Perforated from e.to_fl.below ground surface nature of the material in each layer penetrated,with at least one entry far each change of Sereeru: I@ Yes 0 No G)i:-Packer t • Depth 198 ft. information Use additional sheets ifnecessay. _ • - - From To Manufacturer's Hams Alloy Machine Works \ .: Material N Typo Stainless Slotted Arodel xis. Black medium to coarse sae dy gravel,wet 140 146 I Diameter 55 Slot size.016 in.from 198 ft.to 204 ft. , 146 181 o Diameter— Slot size_!a from ft.to ft. \ Black fine sandy gravel,gray silt binding,dry Slack gravelly medium sand,heaving,water 181 205 s` Send ken pack:❑I'es No Site of pack m terial in. \ Black sharp gravel,silt bound.dry 205 205 0 } 6{aeuiak placed from R.to ft. n `g Sur a e Seal: fd Yes ❑Na To what depth? 20 ft. o Material used in scat Bentonite Chips t >r Did;aay strata contain unusable watch? El Yes b]No s- .T cofwater? Depth of stratao _ — *MOW of sealing strata off ' -o o Pump:Tfanutacu:rer's Name Type O C ILP. Pomp intake depth:—R Designed flow rate: Fpm _ J 0 Water Levels: Land-surface elevation above Crean sea level_f. Stick-up of top()fuel!casing 1 ft.abase ground surface s Static water level 138 R below top Of Well casing Date 8(7/2020 Artesian pressure lba per square inch Date -- Artesian water is controlled by (cap,valve,etc.) 0 _- Well Tests: cs •WasWøaaumping test performed? ElNo ❑Yes t s by whom? -- 'yfpW spin Willi fl.drawdown after—hrs. o Yts _rpm with_ ft.drawdown after his. - Z Yield____gpm with ft.drawdown after hrs. vi Recovery data(rime=zero when pump is turned off-water level measured from well L o top to water herd) w '0 Time Water Level Timis Water Level Time wale:Level I 141 Date ofpumping test - 6 Bailer test_gpnt with R.drawdown after_hrs. I— Air test 30 gpm with stem set at 180 R.for 1 less. - Date 817i2020 . o Artesian flow—gpm g Tempera=of water 51 eF Was a chemical analysisunds? OYes F3No Start Date 818/2020 Completed Date 8/712020 8_ V►!E13..CO.NSTRUCTtON CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well to egilIgnietien standards.Materials used and the information reported above are true to my best knowledge and belief Q ,� CI Driller❑Trainee 0 PE-Pri o Phythian Drilling Company Arcadia Drilling Inc.F •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.ARCADD1098K1 Date 811 912 0 20 ECY 050-1-20(Rev 09/18) If you need this document in an alternate fare nat,please call the ll ater Resources Program at 360.407-6872. Persons with hearing loss can call 71/for Washington Relay Service. Persons with a speech disability can call 877-833.6341- 4, • 0 WATER WELL REPORT CURRENT Oripaai&1"wow-Ecology,2'"copy-owner,3'd copy-driller Notice of Intent No. WE29854 =PANSYMIT 6r ECOLO4Y Co uCtiO CUIIImiSSion("x"in circle) Unique Ecology Well ID Tag No. BKR006 Water Right Permit No. 0 DppQprmi ORIGINAL Noticeof INSTALLATION Property Owner Name Joel&Tammy Stephens Notice of Intent Number- PROPOSED USE: ® Dontestw ❑ industrial 0 Municipal Well Street Address 501 Strong Road ❑ DcWater ❑ Irrigation 0 Test Well 0 Other City Shelton County Mason g TYPE OF WORK: Owner's number of well(if more than one) Location l/41/4 l/4 Sect T�vn 21N R 2W EWM 0 FM New well 0 Reconditioned Method:0 Dug 0 Bored CIDave° (g 6 r Still REQUIRED) Or 0 Deepened 0 Cable ® Rotary 0 Jetted Wes!P. DIMENSIONS: Diameter of well 6 inches,drilled 186 R Lat/Long Depth of completed well let R. Lat Deg 47 Lat Min/Sec liar N CONSTRUCTION DETAILS Long Deg_iv._ Long Min/Sec Sfi'1.37"W Casing 111 Welded 6 " ,from +I.S ft.to 181 R. Tax parcel No.(Required) 284490021 I Installed: 0 Liner installed " Diarn.from ft.to ft. ❑ Threaded " Diann.From ft.to fl. Perforations: ❑ Yes IN No CONSTRUCTION OR DECOMMISSION PROCEDURE Formation:Describe by color,character,sirs of material and structure, Ape ofperfaator used - and the kind and nature of the material in each stratum penetrated,with at ,MZERf _;,,.by• _a and no-ofperfs___from_R.to R. least one entry for each change of information. (USE ADDITIONAL G Sesaaw=:0 Yes I I No ❑ K-Pac Location SHEETS 1F NECESSARY.) FROM TO )+,t>sadscttaer's Name MATERIAL Type Model No. Brown medium sandy gravel,silt bound, 0 t Dians Slot size from ft.to, ft tight 16 Manx: slotsiu from ft to ft. Brown medium gravelly sand 16 21 Cravel/F'Jler packeddatum 0 Yes ® No Size ofgraveUsand Brown gravelly medium sand,silt bound, 21 24 Materials placed from R to R. tight i� Black fine sandy gravel,silt bound,tight 24 31 **egret: ll yes 0 No To what depth? 19 R Brown fine to medium sandy gravel, 31 1t�rhU1.1 used a sral HeolavCe Chios 38 Did any strata contain unusable water? ❑ Yes ® No tight,moist Typeofwater^ Dgrdrofsttala Brown medium sand,wet 38 54 1 4 Msdxdof sealing mataoff Brown fine to medium sand,wet 54 56 PUMP. Manufacturer's Name Gray silty black fine sand,tight 56 62 1{.p, Brown fine sander gravel,tight,dry 62 77 Tie 77 81 1WATERLEYELS: Land-ua6ee elevation above mean 2 level 223 R. Black fine sandy gravel,tight,dry Static level 230 R.below wpofwelt Dare 12/2212017 Brown fine sandy gravel,tight,dry 81 95 f{3 Artesian water in lbs.per square loch Darr Gray clavee silt,some small black,gravel 95 104 Artesian water is contRilIed by (Ca.,valve,a°. Brown silt bound small gravel,tight.dry 104 107 WELL TESTS: Drawdown is amount water level is lowered below static level Gray silty clay,stiff,dry 107 176 Was a pump test made? 0 Yes ® No If yes,by whom? Black gravelly fine to medium sand,loose, 176 l Yield: gslfmin.with ft d awdown after hrs. water 181 Yield: ,gal men.with ft.drawdown aAv ins. Multi-colored pea gravel,tight,water 181 186 Yield: giL/nan.with R.drawdown after bus. Recovery data(lime taken as zero when pump turned o.0)(water level measured from a•eit top to water level) [J r C Time Water Level Time Water Level Time Water Level t� V t_.t Y rr V ta _____ ______ JAN 1 6 2018 sti �h°flat_ WA State Dep,rtmenfi Bailer test gaUtnin.with_ft.drawdown after hrs Q# CCCi�'igy (.�i1�rRO) tilt Ain ll—est I gal./min.with stem set at 160 R for 1 hrs. 15 Artesian flow g.p.m. Date Temperature of water 50 was a chemical analysis made? 0 Yes ® No Start Date 12/21 2017 Completed Date 12l22/7017 ilVf 11.CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards. Materials useit and the information reported above are true to my best knowledge and belief. ! ii, ®Driller 0 Engineer❑Trainee Name p Ian Drilling Company Arcadia Drilling Inc. Driller/Engineer/Trainee Signature Drifter or trainee License No.2053 Address PO Box 1790 City,State,Zip Shelton,WA 98584 Contractor's 12122/20I7 If TRAINEE:Driller s License Na: Registration No. ARCADDI098K1_� Date Driller's Signature: ECY 050-1-20(Rev 02-2010) To request ADA accommodation including materials in a format for the visually impaired call Ecology Water Resources Program at 360-407-872. Persons with impaired hearing may call Washington Relay Service at 711. Persons wit).speech disability may call TTY at 877-833-6341. • 01 WATER WELL REPORT CURRENT F`My Original S 1"copy-Ecology,2'copy-owner,3rd top;-driller Notice of Intent No. WE31576 -)s Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No.BKR144 12) Construction Vi ater Right Permit No. r -. - . ❑ Decommission ORIGINAL INSTALLATION pia Notice of intent Number Property Owner Name Robert Ferrier PROPOSED USE: la Domestic 0 Industrial 0 Municipal Well Street Address 110 Vineyard Dr ©i 3nWatrr 0 lrtiga:ioa 0 Test Well 0 Other . _ - City Shelton County Mason TYPE OriPtinfir Owner's number of well(if more than ore) +' Ncwwell ❑ Reconditioned Method. ❑ Dug ❑ 3ored ❑ Driven Location SEI?4-1/4 SEI.14 Sec 28 Twn21N R211U eWM D ❑ Deepened ❑ Cable ?e Rotary 0 Jetted (S,t,r Still REQUTRED) or W W:St DIMENSIONS: Diameter of well 6 inches,drillk:1166 ft Depth of a nnpkletl well 15611. CONSTRUCTION DETAILS Lat/Long Lat Deg 47 Lat Min/Sec 16'20"N Clain; ® Wesel 6" ()tam,frwn +1.5 n to 156 Si. Long Deg 122 Lone MiaiSec 55'54"W I installed: 0 lens installed " ),lam from ft.to ft_ Tax Parcel No.(Required) 221287790012 1 0 7hresded " Diem.From ft.to fi 1 Perforations: CI Yes El No CONSTRUCTION OR DECOMMISSION PROCEDURE, Type of perforator used _-- Fomtat ion.Describe by color,character,size of material and structure,and the kind and Screens: nature of the material in each stratum penetrated,with at kau one entry for each change & SIZE-of fs_in.by in.and no.of ppees_frrnn ft to ft. of information. (L'SF.ADDITIONAL SI IFETS IF NF.CFSSARY.) g w: 0 Yes rig or ❑ K-Pac Location MATERIAL i FROM _ TO nano re s Nc Brown silty sand:gravel, 0 3 type Modcl No. loose 12 1-'1 Diana. Slotsize from II to ft. Brown medium sand,some . 12 Diem Slot size from ft.to ft Si o gravel,loose Gra ter pecked: 0 Yes El No Sin;ofgravel,smd Brown medium gravel with 51 Materials*cod front ft.to ft silty day binder 57 o Surface Seal: ® Yes ❑ No fo w'}mt depth?191i Brown silty sand,gravel i 57 75 a-a Material used rascal pentonite Chios Brown fine silty sand,gravel 75 i Did any strata contain wwsable U tter? ❑ Yes �7 No wet 95 I k Type ofwatec? Depth of strata Gray fire to medium sand, 95 2 Method of Baling strata off gravel � 97• I PUMP: Manufacturer's Name — Gray clay,stiff (i( 97 1243 a Black medium to coarse sand, i 120 d[.P. 135 T ._ t ., .9ravei,wet WATER LEVELS: Laud-surface elevation above mean sea lest]176 ft Stack coarse sand.gravel. i 135 Static level 100..below top of well Dine 7/30/2018 water 152 AmStanpressun lbs.per square inch Date Brown coarse sand,gravel, 152 Artesian water is controlled by (cap,valve.etc) water 156 WELL TESTS: Draw:elown is amount water level is lowered below static level Was a pump test made? 0 Yes 1,31 No If yes,by.wbont? — Yield nat:rnin:with ft.drawdown alter hrs. 1 Yield: gal.;min with_ft.drawduwo after pus } Yield: >:al lmirn with ft.drawdown after hrs ---'--'--' r Rcvurczy My(time token are cro wltur pump renrc.nf(uar.r level a+ar eJfronr 1 t ndl top towateris ct) 1 } ' Time Water Level Time Water level Time Water Level \ r ii Date of test Bailer test gal./mot.with ft.-dnwdown after hrs. -- Alit' eat gQpl,/min.with stem sat at 140ft,for 1 hrs. Aiautlow_it p.m. Due Start Date 7/3Q12018 Completed Date 7i30/201. I TenweilNrc of water 4s9 Was a climatical analysis mode? 0 Yes El No ,WEI*MOSTRUCTION CERTIFICATION: i constructed and/or accept responsibility for cxrnstructiun of this well.and its compliance with all Washington well won standards. Materials used and the information reported above are true to my best knowledge and belief: Cr'Driller 0 Engineer 0 Trainee Name(mini Josh Kocpp Drilling Company Arcadia[killing inc. Driller trainee 1 mince SignatuNo.2874 �- Address Po Aug 1790 Driller or trainer License tin.2874 � City,State,Zip Shelton via, 98584 IF TRAINEE:Driller's License No: Contractor's Driller's Signature. Registration No. ARC ADDIO98K1 Date 7!30.12018 1 ECY 050-1-20(Rev 02/10) If you need this document in on alternate fanrrat.plemry call the Water Resources Program en 360-407-6872. a Persons with hearing last can call-i 11 for It ashingtnn RelayService. Persons with a speech disability can call 877-8,33-6341. 1 i 1 V' m • go yssyd 0 x a z o z 1Id N10 K o x Q N�-]1+rMi gt hi 0 E 0 .1. >0-4 ci cs . ,,, Fa, z,.,1 ID,---- i'101r4 $,,, ...... . o N OSrcs000z l INI A l'''''''''''''.7- '''''' EFc, '42.° Q" g 5 O 4 I E I 5 E, - ,90q1 !___J c)WJQory c.--. N \ n`J r� o.n ?Di t4 .0 \ / C µme- 1 tv R.g 14. qr., Z � I., H 0 �00 ii-IE r it Od Y 'cc b� fTl 1- °c \� W Vie° \�a xGG co IMIA \\ \\ 14 IN \\ 1 \\ ow \ \ g6) S .,,,-, . • ,..' /. . . . . . •v ti! ..a 1 r • o•O z t o • t 0 p a o \ p 4 tamg \E m' . • 4' \\ o • r: I • � N .Pp - ALP F"1 W N y. , , a • at GO l:d From Mason County D ME* - p-„t,t,.d f".era PL.,"Ct5tttt4--PMC