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HomeMy WebLinkAboutWEL2023-00030 - WEL Application, Design, Letter - 6/16/2023 584 MASON COUNTY 415 N 6TH STREET, 0427-9 7 , E 98400 SHELTON:360 427-9670, EXT 400 • cr BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 FOREST MAJEURE LLC 2460 WESTLAKE AVE N BOAT ST SEATTLE, WA 98109 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00030 520 E South Island Dr 220103091002 The 2-party water system, Major 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, David Anderson Mason County Environmental Health r ; '•-• MASON COUNTY Date Received: (� - ` ` 2 mot'''. COMMUNITY SERVICES R... _Y r � Building Planning Envr W onmenHeshhCommunityelth '�\� 415 N.66 Street,(Bldg 8)-Shelton.WA 98584 WEL ..--0 1-- U OCR 3 Q Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360.482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE G,1>-r-I-1 a 11~t'l- t--41.i oe--- zo(o. c'153.ft,2-7Z MAILING ADDRESS-STREET.CITY,STATE,ZP z4(vco le >Tt_ 1 -t i-r I `9ra'i1-LL.. W k► Sp,locl SITE ADDRESS-STREET,CRY,STATE,ZP '7-0 -r -f`FN te-- --4D bv.1 V 54-f'.*L"frn-4 1 \ .j pg- 98 5.84. PRIMARY PARCEL NUMBER(WELL SITE) 2.2.01 0- 3o-- C1100Z, SECONDARY PARCEL NUMBER(IF APPLICABLE) 22c l o - 3o .-- el 1tx _ \ WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE XNew 0 Existing Well 0 Spring ` D. 1 l p. PROPOSED WATER SYSTEM NAME(REQUIRED) J. 0 r va� �1 7/ eiAl PROJECT DESCRPTION I ` 1-tIF-4 Iyw e 'r-cAg-Y `715 `f t . -A► U 21l v%--( tiv- DIRECTIONS TO SITE/CONDITIONS -T 1 4 t r t-FT 1 t-lTo D l-0ti../ VWts Cct 1,'�( 4D Ye- Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) po.A.c 7 11 5C� p �) ✓ J�a �� , _ , , JUN20 RE(.:.. .., JUN 16 2023 �LJ @...v By 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 r _--------------------------------------------------- Staff Use Only ----------------------------------- ------- Review Step 1: Well Site Inspection: YES .. NA ❑ r�� ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ [p ❑ Are there roads within the 100 foot radius of the water source? If so, is road private,County or State. What is distance to ROW? 0 ❑ Does the ground slope away from the water source site? (show slope on plot plan) p- 0 ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? II L 1/ ❑ The well casingextends l > above level ground/concrete slab? (circle one) R0 El Is there evidence of a surface seal? Af: t 1. i3 500 .❑ ❑ Does the seal appear adequate? (NI —l a ,72 Hy i6 ❑ ❑ Is a variance necessary for well site approval? Comments • /*- ass ❑ Fail Inspector Date -z4 Review Step 2: Two-Party Review: YES NO NA 0 ❑ El Water Well Report with adequate pump test on file? 7(9(ZO 2 Z' If NO,date of Capacity Test Driller ,4rCGdi AI""� GPM Zo El Received Satisfactory Bacteriological Analysis? Date of test17/ OZZ �( El ElReceived Signed, Notarized, and Recorded Notice? AFN Z( Y ti gi El ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments (re Approved ❑ Denied Reviewer il2Date 60(M7 )Z . 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. I 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 DEPARTMENT Of Notice of lntenl No. WE49142 ECOLOGY Unique Ecology Well ID Tag No. BNV853 Type of Work State of Washington O Construction Site Well Name(it'more than one well): O Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Catherine Maior 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 520 E South Island Drive Construction Type: Method: O New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug R Air- 0 Mud•Rotary Tax Parcel No. 22010-30-91002 Dimensions: Diameter of boring 8 in.,to 115 ft. Depth of completed well 115 ft_ Was a variance approved for this well? 0 Yes ©No Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread 1 f3 I ❑ 6 in. 0 1 to .02.5 in. Cg I ❑ l7 1 ❑ Location(see instructions on page 2): Ii WWM or 0 EWM ❑ 1 ❑ in. ia. ❑ I ❑ ❑ I ❑ SW %-1/4 of the NW ''h;Section 10 Township 20N Range 2W ❑ 1 ❑ in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ ❑ I 0 in. ^ _ in ❑ 1 O ❑ 1 ❑ Latitude(Example:47.12345) 47.235003 N Longitude(Example:-120 12345) -122.924528 W Perforations: 0 Yes O No Type of perforator used No.of perforations Size of perforations in by in Driller's Log/Construction or Decommission Procedure Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material is each layer penetrated,with at least one entry for each change of Screens: Ii)Yes 0 No lift K-Packer Depth 109 ft. information Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works _ Material From To Type Wire Wrapped Model No. Diameter 5' Slot size.014 in.from 110 ft,to 115 ft Brown gravelly fine sand,tight,dry 0 9 Diameter Slot size in.from _ft.to tt. Brown fine sandy gravel,silt bound,tight,dry 9 33 Sand/Filter pack:0 Yes E No Size of pack material in. Brown fine to medium sandy gravel,tight,welps 33 66 Materials placed from ft.to ft. Black fine silty sand,heaving 66 74 Black fine to medium sandy gravel,tight,wet 74 76 Surface Seal: O Yes ❑No To what depth? 20 ft. Gray day,stiff,dry 76 98 Material used in seal Bentonite Chips Did any strata contain unusable water? ❑Yes a No Blanc gravelly medium sand,heaving,water 98 115 Type of water? Depth of strata_ Black clay like silt,soft 115 115 Method of sealing strata off Pomp: Manufacturer's Name Type: N.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 56 ft Stick-up of top of well casing 1.4 ft above ground surface Static water level 51 ft.below top of well casing Date 9/8/22 _ Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? E No 0 Yes =J by whom?-__ Yield gpm with_ft.drawdown after his. 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 lop to water level) Time Water Level Timc Water Level Time Water Level - — Date of pumping test Bailer test gpm with_ft drawdown after hrs Air test 20 gpm with stem set at 100 ft.for 1 hrs. Date 9/8/22 Artesian flow gpm Temperature of water 51 0 E Was a chemical analysis made? ❑Yes ®No Start Date 9/8/22 Completed Date 9/8/22 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 O Driller 0 Trainee 0 PE— ' me Rogeray Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No.2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Lic o. Contractor's Sponsor's Signature _ Registration No.ARCADDI098K1 Date 9/8/22 ECY 050-1.20(Rev 09/18) 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. 1786 SE Mile Hill Drive Port Orchard,WA 98366 J( SPECTRA Laboratories-Kitssp www.spectra-lab.com ..raen eer^b,�a.:e . (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Colecled Time Sample I County Collected 9 f 20 / 22 clam Mason eb,rh Dq Ye,r 3 . 60 QJ Per Type of Water System(check only one box) ❑croup A D Group B 00mer Group A and Group B Systems-Proude from Water Wiles Inventory(WA): IDq System Name:Forest Majeure,LLC Co tact Parson:Arleta Eisele/Arcadia Drilling Day Phone 3e0.426-3395 Cal Phone: Emet arlebiparcadiadrlllIng.00m Eve.Mons Send resits to fit lemma address ad rip code or e-0raq arteta@arcadteddifing.com Arcadia Drilling,Inc &A PLE INFORMATION Sample collided by(aarae):MAX Speddc bcallon where sample collected: It isdd Unbudllons or comments: #8NV833 COUNT$PLEASE 520 E South Island Drive,Shelton Type of Sample(check only one boor)I.0 Routine Distribudon Samp a 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ 0 Distribution System Chlorite Residual:Total_Free Unsatisfactory routine lab number: 3.Source Ground Water Rule Sample` s I Unsatisfactory routine collect date: ! I D Trfillgered Chlorinated:Yes ElNo❑ El AssessmentChlorine Residual:Total Free_ 4. Enumeration Source water Sample I.8 I I I E.coif Erecal-swam,ant.sprit¢Mind r.. No 5.El Sample Collected for Inbrmaeon Only: LAB USE ONLY DRINKING WATER RESULTS LAB ONLY D Untatiebdory Total Coi'rform Present and tisfactory ❑E.coi present 0 Eco/abaent Replacement Sample Required: ❑Sample too old NO hours) D TNTC . SG sQ[3 Bacterial Density Results:Total C T .EcoN gr100m1. Fecal Cotiform 1100m1 HPC_ _ !1 ml. Lab ID taunter Day al2°11 Me nod Code Day and Time imitated SM92238 'J 11 La DateA"a"zhi SEP 2 2 2022 D iReQotted:SEP 2 2 2022 DOH Lab-S Lab Use ody: 400.„ 225 . LA o Pii;11111Tii e«+n•l *sodere+1c+rm1,.a.e!.fe..k�ez�d'ro--tirearr97:00.5.— Th s w oss pJdubeae voted*Kw.e,Aae caidi-Wpdir. © _ O N m r O '3 Z c v Io 0 mo � � �• D `Iz A I� � z 0 . .. 00• v ry / ' <i � - � mO \ m rn z , n _ r 1 j p m 11% 0 n I1 n+' 7� 0 m j � S i m z P. n �m d Jr. / -1z dC mW a 9rF �r. r Dm A A Cr':',. i1 c;kei', _ lI m r. < 1 .I '. •.. 0m9a N vt)* „/ V ---— — --- --, ._ 1 . / , _ _ , � S -< DOv, � . 0 M iv m .. m m 9 A 9 < \, G m m '` vn D j \`-� N � 2. / Z 0 ,I —— _ n m D (-- D ) rn i � 00o m - -o x�Uo 0 mx 11 -nN UJ ' 1 . . < < r 2198413 MASON CO WA 06/16/2023 09:03 AM NOTCE MAJOR #187852 Rec Fee: $204 50 Pages: 2 Return To M �-t G_ogt -t T `f Jx-1 P )s gS25 Grantor(s): (1) G,b' -1 -S1- 5- t'''fAl -- , (2) Grantee(s): (1) PUBLIC Ne t/d. a 1/q- 4c11b*J v `r'oitl-1 t1P Legal Description (1) 1-1'- h% µC Z k2frf1 La. 74. (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) Z Z o I - - 1 I 0 0 Z• 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 2- d 1 0 - 3 - at l o v Z. Tax Parcel: (Connection 2) 2- Z O 1 b - 3 -b - q 1 o 0 -Z, The system owner is responsible for keeping this system in compliance. The name of the water system is: 'a -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 /-2- day of Ci , 20 2-3 Signature • (1) , (2) Page 1 of 2 I State of Washington ) County of Mason ) I, the undersigned, a-Notary Public in and for the above named County and State, do hereby certify that on this I day of J,it i , 20 ? , Cc-4 c;Kl afjc,r 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 ear last bove written. d otary Public in and for the State of Washington, JOHN T EDWARDS residing at (E, WA ' Notary Public ' My commission expires: Vet State of Washington Commission rt 198540 My Comm. 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