Loading...
HomeMy WebLinkAboutWAI Health Waiver - 7/17/2023 7,;-,—„„st, r�,.,., �. MAS ON COUNTY ii '" ' i COMMUNITY SERVICES i, .'r �`�t� 1+1w�`��d Building,Planning,Environmental Health,Community Health 415 N 61' Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360) 275-4467 ext 400 •: Elma: (360) 482-5269 ext 400 FAX (360) 427-7787 Application for Waiver/Appeal Amount Paid: Receipt Number: Instructions 1. Complete Parts 1 and 2. No determination can be made until these parts are fully 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 Identification Name of Applicant RON MCKUNE Telephone 360-970-9532 Mailing Address of Applicant 4330 LEGACY DR NE City OLYMPIA State WA Zip 98516 12-digit Tax Parcel No. 2 2 1 0 5 -- 5 1 0 0 0 7 8 Site Address 3200 E MASON LAKE WEST Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation 0 Food Sanitation Requirements 0 Building Permit Review Policies 0 Group B Water System Regulations ® Location, WAC 246-272A-0210 0 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Other Description of Waiver/Appeal (include justification, additional material may be attached.): (b C ai REDUCE HORIZONTAL DISTANCE FROM NEIGHNBORS WELL FROM 100'TO 75'. REDUCE HORIANTAL DISTANCE FROM OWNERS WELL TO DRAINFIELD FROM 100'TO 75' Applicant Signature: REPRESENTATIVE Date: J:\Ell Forrns1 Wainer-Appeal Mason Count) Local Revised 1/20/2017 Page I o12 l (CC PART 3: Public Health Evaluation (Staff Use Only) 1 Type of Determination Required: Type of Onsit- 61i- (if applicable) Appeal Waiver None required Class A .�f� + Class C Ili".iirj 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/ Standard revision) 246-272A-0210tABLE IV 3. Nature of Appeal: REDUCE HORIZONTAL DISTANCE FROM ON-SITE SYSTEM FROM 100'TO 75'FOR TWO NEIGHBORS WELLS. OWNERS WELL AND SHORELINE 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board ® Environmental Health Manager 5. Mitigating Factors: DRAINFIELD MEET TREATMENT B WITHOUT DISINFECTION,DRAINFIELD IS DOWNGRADIENT OF NEIGHBORS WELLS VICINITY W l OGS INDICATF AQLIARTARDS(HARDPAN CLAY BI 1 (I AY) OWNERS WELLIS UPGRADIENT. INAL DESIGN SUBMI l I ED IN 2/2023 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: vV bA-0.72., Date: .7 ( 7 .- 2 3 PART 4: Determina ion of the Hearing Official LThe 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: El 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: Hearing Official Signature: — Date: r7. 21 .I:iFlI Forms\Waiver-Appeal Mason(bunt'Local Revised I/20/20I7 Page 2 of 2 Cindy Waite 80 E Pickering Lane Shelton, Wa. 98584 360-426-2113 360-701-0205 cindyewaite a(�msn corn February 22, 2023 Mason Lake House LLC 3200 E Mason Lake Dr. W Grapeview, Wa. I am an State of Washington licensed on-site wastewater treatment designer. I have designed a system for Ron McKune at 3200 E Mason Lake W. I have applied for an on- site sewage system waiver. He will be locating his drainfield 75' from your well. His system is down gradient of your well, meets Treatment level B without disinfection. The system will be augmented with 2' of sand with pressure distribution and time dosed. Wells in your location show aquitards(clay or blue clay). I am required to notify you by registered mail and inform you that you have the right to appeal this waiver. Mason County Health Department would be able to help you with this process if you want to appeal. Respectfully submitted Cindy Waite Cindy Waite 80 E Pickering Lane Shelton, Wa. 98584 360-426-2113 360-701-0205 cindyewaiteAmsn.corn February 22, 2023 Sean Koval 7209 47th Ave NE Olympia, Wa, 98516 I am an State of Washington licensed on-site wastewater treatment designer. I have designed a system for Ron McKune at 3200 E Mason Lake W. I have applied for an on- site sewage system waiver. He will be locating his drainfield 75' from your well. His system is down gradient of your well, meets Treatment level B without disinfection. The system will be augmented with 2' of sand with pressure distribution and time dosed. Wells in your location show aquitards(clay or blue clay). I am required to notify you by registered mail and inform you that you have the right to appeal this waiver. Mason County Health Department would be able to help you with this process if you want to appeal. Respectfully submitted Cindy Waite 1 0 Cl. - ��� . Ct WATER WELL REPORT ECOLOGY Original&f' copy-Ecology. 2n°copy-owner. 3"copy-driller CURRENT Construction/Decommission ('k"in circle) 32 .—I '52 Notice of Intent No. W E09655 to Ill 1 t/ Unique Ecology Well ID Tag No. BBE037 't El Decommission ORIGINAL INSTALLATION Water Right Permit No EXEMPT WELL of Intent Number 0 PROPOSED USE: x Domestic Property Owner Name ALLYN FIOEFS ❑ ❑ Industrial ❑Municipal E Dewater ❑Irrigation 0 Test Well ❑Other Well Street Address 3100 E MASON LAKE DR W OTYPE OF WORK: Owner's number of well(dmore than one) City GRAPEVIGW? CountyMASON E New well 0 Reconditioned Method 0 Dug ❑Bored L I Dnven 0 Deepened E Cable ❑Rotary n Jetted Location NE_.I/4-I/4 NE 1/4 Sec 5 Twn21N R 2W EWM ❑ check E DIMENSIONS:Diameter of well 6 inches.dolled 108 ft (S,t,r Still REQUIRED) Or One 1 Depth of completed well 08 ft Wwnf❑ tt- CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec Casing DYY'elded 6 " Dam from 2.0 ft to 105 9 Installed: 0 Liner installed - Dian from ft to ft Long Deg Long Min/Sec _ ❑Threaded " Dunn Front ft to n Tax Parcel No.(Required) 221055100085 4.1 Periorattons: 0 Yes G No 1- Type of perforator used I'ormahon Describe by color, liar .OR DECOMMISSION o PROCEDafenal and URE titre,and the kind and SIZE of perfs in by in and no of perfs from _ft to ft nature of the material in each stratum penetrated,with at least one entry for each change V Screens: of intom?ation (USE ADDITIONAL-SHEETS IF NECESSARY) C ❑Yes ❑No []K-Pat Location 102 (U Manufacturer's Name JOHNSON SCREEN MATERIAL FROM TO CU Type SLOTTED Model No Gray hardpan 0 +-ii Dram 5 Slot size/0 from 103 ft to 108 ft Gray conglomerate y aa Dram Slot size from ft to ft Dull brown comglometate Gravel/Filter packed: Bright brown comglomerate • p 0 Yes Q No Stzeofgravelisand __ 8 I Materials placed thorn ft to lt Sand an gravel wet .)„ 4-' Surface Seal: ieGray conglomerate 53 ❑ Yes 0 No To what depth' 3 I ff =g Matenal used in seal BENTONITE CI LI PS Blue silts 58 I61 4-0 CGray/blue comglomeratc 61 179 Did any strata contain unusable water Elyes ENo iType of water'' Brown conglomerate 79 197 >D Depth of strata Brown silt bound sand and gravel 97 103 L. Method of sealing strata oR Sand and gravel water bearing 103 108 PUMP: Manufacturer's Name I'-- ryPe II p I 0 WATER LEVELS: land-surface elevation above mean sea le,el n Z Static level 67 ft below top of well Date 7/8/2009 I (/) Anesian pressure lbs per square inch Date OArtesian water is controlled by (cap.value,etc) (*] rIs-O I l "0 WELL TESTS: Drawdown is amount water level is lowered below static level C 1-4 Was a pump test made'? 0 Yes ❑x No If yes,by whom" .y CP Yield gal/min with ft drawdown after hrs r-- G Yield gal(min with fl drawdown after hrs C' Yield gal/min with ft drawdown alter i'� 0hit <r .. -.. to Recovery doto(time taken as zero when pump turned off)(water level measured from well G C.' in LV top to water level) r 1 - W Time Water Level Tune Water Level Time Water Level CV— I,, E — -- 0 ins M • ka +.A —� II C CDII EDate of test Lnailer Test 10 gal/min with 2 ft drawdown after 4 hrs ca Airiest gal/min with stein set at It for hrs I CDArtesian flow _g p in Date Q Temperature of writer 51 Was a chemical analysis made' 0 Yes E No Start Date 06/30/2009 _ Completed Date 07/08/2009 C) -a 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 arc true to my best knowledge and belief []Dnller❑Enguleer❑Trainee Name(rant) R k N � DrillingCompaoy ARCADIA DRILLING INC Driller/Engineer/Trainee Signature- _____J ddress P()BOX 1790 Driller or trainee License No 1992 _. I TRAINEE Drillers License No City,State,Zip SHELTON , WA 985f' Contractor's Ucller'sStgnaturc g ARCADDI098KI I Registration No Date 07/08%2009 EC'Y 050-I-20(Rev 06/08)If you need this document in an alienate,format.please call the Water Resources Program at 360-407-6600 Persons woh hearing loss can call 711 for Washington Relay Service Persons with a speech disability can call 877.833-6341 I 1 1 Cr it;1Jti l'iC-ie File rJrlglnal and First Copy withWATER WELL REPORT ; star,Card No. 067396 p DsAM re. of ecology Second Copy-Owner's Copy STATE OF WASHINGTON •hh Third Copy-lxieer's Copy Waldo flight Vomit No. 4- i (1) OWNER: Name Charles Gordon Address_ 4320 Mdson Lk Dr W Grapeview WA 98546 0 • (2) LOCATION OF WELL: county Mason . NE M�NW a sec_-5__--T 21 „,R_ .- a) Cr (2a) STRUT ADDDRESS OF WELL(or nearest address)___4320 ?son hk Dr W Grapeview WA 98546 tL (3) PROPOSED USE: E Domestic Industrial 0 Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDUt . i.. Irrigation ❑ DeWater Test Well ❑ Other D Formation: Describe by color, character, size Cl malarial and structure, ark _. N thickness or aquifers and the kind and nature of the material In each stratum penetrated, (4) TYPE OF WORK' Owners number of well wf h Cl least one entry for each chsnqe of information. • (H more than on.) -iJ MATERIAL FROM TO .- Abandoned (] New well 3 Method: Dug ❑ Bored ❑ --_ -- , C O Deepened G Cable aDriven 0 Reconditioned G Rotary 0 Jetted CI Hardpan 0 75 O (6) DIMENSIONS: Diameter of well SU 6 Inches. - a Drilled 93 feet. Depth of completed weer 9'i ft. Sand & gravel with water 75 93 E (6) CONSTRUCTION DETAILS: w Casing Installed: 6 • Dlam.from 0 n.to 88 n. _ __- _ --- - _ C Welded ' Dian from ft.to ft. Cher Installed - - ----- 01) Threaded ' Clam.from N.to ft. .--.-. ids Then en Nola - -_. --- — — --------- a- Type of perforator used r—— OSITE of p.Aoratione in.by h. — Cperforaf Ions from n.to- ft. ta perforations from ft.to A. (13 perforations from ft.to ft.- - aa Scfe.tle: Yea® NOD Manufacturer's Nuns Houston CIJ,� Type frstainless Model No �' Clam 5 Slot ails hoer S8 h.to 93 n. — Olam _-Slot alze r'7 horn n.to h. -- 1 (Q Grevel picked: Yasn Noll Size of gravel ' 1.. r s- Graver placed from ft.to ft. fa Surface seal: Yes® Non Towhaldapth? 18 ft. 1- Material used In seal Ret.nni t P - 0 Did any strata contain unusable water? Yee0 Plo® -- - z Type of wstw'1 Dopth of strata -- -- _ --- V) Method or sealing Ural.on ^- - O (7) PUMP: Manufactur«'swore Sta-Rite 13 ›.. Typal sub. _H.P of (8) WATER LEVELS: arboY•riin aM kgr rt.O Stink layer 6.8 ft.below top of well Date - ✓ M.elan pressure lbs.per square Inch Data _ T LLI Artesian water le controlled by- (Cap,valve.inc.)) 4- Work started 9129192. ,to. Comp1.ted ,I _ O (9) WELL TESTS: Drawdmi la am nt water level Is lowered below stalk level I . Was a punk Mori made?Y.sLJ No kJ RYes,bYwhom? WELL CONSTRUCTOR CERTIFICATION: Yield: pal.f trio.with ft.drawdovvnaner hre. I constructed and/or accept responsibility for construction of this we*, and its compliance with all Washington well construction standards. y,t ,. .. •• •. Materiels used and the information reported above are true to my best s- knowledge and belief.(Q Recoveryhe data(time token as zero when pump turned off)(water t.r.l measured 1Z from well top to water level) CD Time WaterLey* nine Wet*,Loyal Tim. WaterLwai ClJ NAME DavisDrilling (PERSON.ARM.OR CO RATiON) - W Address Belfair WA 98528.0 1-- — - Cate of test (Signed) pit........_,_ License No 1706 Beller test gal./min.with 12 ft.drawdownafter L. hr.. EWELLDAILLEfU Contractor's Alrtset. gale f mlr.with stem set at-_- -ft.for MIL RogistuitIgn.SDT 11(X)A Date QC t •t9-�.2 Artesian flow g.p.m. Date-_---_--_--- No. Temp.reture of water_Was a chemical analysis made? Yea❑ 14 1 (USE ADDITIONAL SHEETS IF NECESSARY) 0 ECYOd0-1.20 (1047) •1321L T.,10.44.ie (J-t Cr IJ'r GJell Start Caw No. L 0 i3i)c) FilDe resnaland First cOogCopywin, WATER WELL REPORT utiIOUEWELLI.D.a A cY 81 1 Dea•tutat>t at�aogy 2accidCopy—O m.r'a Copy STATE OF WASHINGTON Third Copy-DI111N•e Copy Water Right Permit N0. L (,) OWNER: Name f rt1 - T4 O.,wu/'`.`- -.. _ Address k .2, 43v iso ,/ �Lk 7; S• 'o /�! ' CL J U v� tit!�/ K�.v Sac ti.?Y T t N..R OC W.M. Ce w (2) LOCATION OF WELL: c„,rty / (2a) STREET ADDRESS OF WELL cot nearest address) .2 r) "-LQ )+.r.. L c Dr_, 4✓., 1 _ • (3) PROPOSED USE: ›ie Domestic tnduabrat r_-] Murticipet G (tO) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION C] Irrigation Test Weil other C Formation.Oe.crlbe by odor.charade/.si>ra CS rnatariaf and structure,end Neat ness ck wave waveCA C OsWaler , and the klrw and nature or the molded/it In each stratum penetrated.weft at Oast one[miry for each (4) TYPE OF WORK: Owner's number o?"II cheeps d inlc match (e mare man OM)-.____...._.._.__--._... __ _.__ MATERIAL PROM TO Aoanaoned 0 New wail -per.. Method: Dug 0 bored C. 0O Deepened 0 C Driven c 1i';o 5... 1 c w/S •it._ 0 Reconditioned Ro 7 Jetted C C 'z ` O_ (5) DIMEN : Diameter al wee_—_ 41 _—.0---.----- incites. y red 1'O t�n $ h Cl, Cif,,,, cl"% 5- Y co Chilled_ T feet Depth of oomplaed wee- Y I I, (n/ (6) CONSTRUCTION DETAILS: i // ---- -- 62_--• Dlam from 4 h.a 3 9 f. Casing Installed: ` C Wttaed4nowieeK _ ._: Diem.from__._.._—It.to — ft Traded 0 Diem.?torn h.to h. - - - -- --- -. CU -_ --- ... --_-- _.. .— 4.1 Paseoretlenst Yip 0 NoS, ____--- O Type of wno<.a.used __ ---- - --- SIZE of peRortatlons ..._._-in.by__—_--.-- In. _ pert/shone from _._.._R.to ft -•----J.-�— C •-- - _-..__. -� -- t'•Q _--- P�«oboes IiOm it.to e. _ 03 pafaadons horn A.to N. 4.0 ea 5Ci Sena: Ytaao No 0 MA Manufacturer's Name _ pi w 1:.w___ _ _--_ _ _ - - - Type .. .-4-�:..�i ,. - -r-4- . __Model No r 4' Dlam. J.Slot Site a tram 3r (! _.-h to �+S/ h. .' C \/ ,_ Dam. Sid size from ---.. It.to — _—N. , El — (U (revel peaked: Yes 0 1 o, . Size of gravel tr 9O _ y" ft to N ��l'Ihtt;lai CL.0 Gravel pieced from ._ .. --- ___.- -...__ -1 WFCf 1 .1."..Ir,_IP,IT _— surtac.seal: Yes '- 01q 0 To what ceps? 18 fr I— Material used m seal N t k'L rl ,,t it - O Did any strata contain unusable watery Yea 0 No ' - _—�_ Z Type of water? _....__..-----_ Depth 01 strata , - --- N da.eeirp'strataoe _.._ _ _ _ ----•-_-_---- •---- __. __—_......- -- o ,_� -- (7) PUMP: Manufacturer s Neme - -. MI TYRO: N.PCR -- (6) WATER LEVELS: i+b eweaa*ovation Week stanw -�-�___• ad . 'a--L 1.? abOv.than sea avat-tar- .. � O Static t.val .:;p f — h txiow cup m weP bete J j�-q WELL CONSTRUCTOR CERTIFICATION: ✓ Meson onesura -_- 'bt.per sgwre och Date Masanan/a controlled by - I constructed and/or accept responsibitky for construction of this well, and its L1J w (Ccy.?I itc.l complance with al Washington well construction standards.Materials used and - the information reported above ere true to my best knowledge and bet*. • (9) WELL TESTS: Orawdown is amount water levet is lowered Wow static iewi n C CWas a pump fast mode° Tel C No 0 ft yes.oy whom .. - NAME -- O F� r w �' — CD Yield. gal./rtun.with N.drerWo'wn altar __-- ivy � 1 � � � � ` J' Address -.. o, <. t r to _ .�. -- --- (siprted) . License No. Q Recovery data(time talwn as zero when pump turned*(water lave;Matured hen wee u O top to water isvet) 0 Timor Water Lee Time Water Level Time Water Level COnkacfa- t 4 _ Noe,M2(14( 0_cY kt 7 Date tr'-' t t9 )' --_-- — __-_ — _., —_ _ . _-.—___ (USE ADDITIONAL SHEETS IF NECESSARY) Dais 01 teat Baiter aV.,0._pal imin.with-_ ft.drawdown star_ 1 tire. Aideet gat/thin.with stem sal et _It.for_.__-_ ____ tire. Ecology Is an Equal Opportunity and Affirmative Action employer. For ape- Artesian?trove. __. _ . , ,-g p.m Otte ClaI accommodation needs,ContaU the Water Resource3 Program at(206) Temperature of water _.__Was a chemrcat analyeis made Yes ❑ 407.6600 The TDD number is(206)4(tT-B006 V t C r ,fa t Yy Gs)t(/ File Original and First Copy with Stan Card No, `�/��73 O G Department of Ecology WATER WELL REPORT UNIOUEWELL1.D.s /d1 �"LG1 7 C Second Copy—Owner's Copy STATE OF WASHINGTON Third Copy—Drillers Copy iy Water Right Permit No. 0 (1) OWNER: Name ern G 4 J - , (ja r41 e- Address 7 3C r I-1` .r1 I, :. C�/ 4) (2) LOCATION OF WELL: County /C /��/ (J) ct µ J�',r1 /Y Y1 1/Af�11LII sec `� T / N.R .� �'W.M. dl (2a) STREET ADDRESS OF WELL;or nearest address) at 3 3 7C /��{5 /'1 4 4 Dr. 1.47 ,j/E' /JC-‘? (3) PROPOSED USE: .Xa Domeshc Industrial D Municipal r- (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION ❑ Irrigation Cl) ❑ DeWater Test Wall ❑ Other 1_.; Formation: Describe by color.character.silo of matenal and structure.and show!ti dcness of aqueers and the kind and nature of the material in each stratum penetrated.with at'east one entry for each 4.0 (4) TYPE OF WORK: Owner's number of wOt change of information Of more than one) - MATERIAL FROM TO 0 Abandoned I New wet Iw' Method: Du Bored❑ _.� Deepened ElCab&,. Ddvenf-: 5 AAt) L'_ J3Cc..a..,,/ La_taL '�_ - C Reconditioned[I Rotary Li Jetted L: ,L L. 7.. 3 eta t,.....1 _Lk/ :F.t (5) DIMENSIONS: Diameter of well_ '�j ` Inches. � g Lty See/f 6,j.,,,�f v.,*4.4L r Z_ cu Drilled f 410 feet Depth of completed wet / 7 n. ix L .- 431.y Ci _ .2___z E ilz D -S,.r,d 6e 4 s t y r✓ 31 0 (6) CONSTRUCTION DETAILS: i -�- - -- GCasing installed: Diam.from d ,� ft.to �_y�n. •`` ✓ to (L,, q4, Welded . __ - Via► [LyPy�J .. GILN •IDSG ! ! er installed C Diem.from_ ft.to n. 4J Threaded E. ' Diam.from n.to ft. t�Cry -�K'er S rR ray /UAt.f i 8 4 L Perforations: Yes NA t/ - 0 Type of perforator used _ A/p Lr�•v f�..era!'T- y SIZE of perforations in. - --in.— ifi O .TJar.r�J �:...,•-kj coue4:' slrq,-,Jr 1 act C by 1 n - perforations from _n.to ft. f�1 LG ��wr A y 3 t perforations from n.to n• f.,-�✓Z►a •co•-.1' �3ctL 04AyPSA,--1 S' I 34, oci t ta perforatons from It.to n. "CL /�` J �� y� ,ut S,4.�t CCU yv.r-/ ii.ji 1 Si/ Screens: Yes NO❑ NLL� si'C ,,.d .. SS�-t-gf A •//G�711II a►L "Z��. ..1.=7 Manufacturer's Name , .j/d G e K.4_ _ - 7-i[.4 �a £ !�"; 4. Type r.5'S Model No. C P .'77 _. .. _ ' . Diam S Slot size a f`g 1rom� y ft.to / I f n. .1 0 Diam. _ Slot size _" y� from ft.to n. L. Gravel packed: Yes [, No, Size of gravel L. 03 I Gravel pieced from ft.to_. ft. _ Surface seal: Yesogi No ElTo what depth? I D ft ^'- Oh I— O Material used in seal /3 P.r.'i'Q.rty,-r€, or' z Did any strata contain unusable water? YesrC_ Nod! y Type of water? Depth of strata_ -- — -. OMethod o1 sealing strata oft _ a (7) PUMP: Manufacturer's Name Type: —. .. H.P. ._ _ .. ._ 0 (8) WATER LEVELS: 1-and-surtace elevation Wak sta_ �/ y-'r0-- -'7 a mean sea level__ _ ,.�'Y`' n. "6"`a+'4'y O . •19' Conykttad.-��j y,�L,V. .19 9 i U Static level_- _ J .---. ---_- 11 beige/top ewe Darr yy- LIJ Artesian measure lea per square teal Date �i�' WELL CONSTRUCTOR CERTIFICATION: O map.valve,etc)Artesian wale,is controlled by _ I constructed and/Or accept responsibility for construction of this well, and its compliance with all Washington well construction standards.Materials used aryl 4.4 (9) WELL TESTS: Drawdown is amount water level is lowered below static level the information reported above are true to my best knowledge and belie'. ty Was a pump test made?Yes❑ No a If yes,by whomv NAME l f.C G('r L'''E 4( t(y/ L// �/♦//7 r[!ire l/e EYield: gal./min with ft.drawdown after hrs. --' J tPEnsON,FIRM.de Cori Ttprq (tyre on PgetTt L. n / RI Address t> 7/'j�fL C/C/� /G VZ7 4f �r��G' %'l U Recovery data(time taken as zero when pump turned oil)(water level measured from well (Signed) c Lr . _.—License No. p�(,4 oS o top to water level) Time Water Level Time Water Level Time Water Level 11) Contractor's // {� /j t — Registration L �- U/ / 7 Date -; �C. — 7 7 19-- .. (— Date of test 1 (USE ADDITIONAL SHEETS IF NECESSARY) Bailer test () gal./min.with I CS n.drawdown after hrs. Ainest gal.linin.with slant set at h.for hrs. Ecology is an Equal Opportunity and Affirmative Action employer.For spe- Anesian flow _ g.p.m. Dale cial accommodation needs,contact the Water Resources Program at(206) Temperature of water _Was a chemical analysis made? Yes❑ No❑ 407-6600.The TDD number is(206)407-6006. ECY0.S0-t 20(9/93)"i VT e 1"w L41-e-I I 04✓iV - Gi,e.d /dr r r WATER WELL REPORT DEPAgIMENT or Notice of Intent No WE51879 ECOLOGY Unique Ecology Well ID Tag No BNV804 Type of Work: State of Washington G ConstructionSite Well Name(if more than one well). ❑ Decommission Onginal installation NOI No Water Right Permm'Certificate No Proposed Use: M Domestic ❑Industrial 0 Municipal Property Owner Name Ron and Gina McKune 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address 3200 E Mason Lake Dr W Construction Type: Method: C New well ❑Alteration 0 Driven 0 Jetted 0 Cable Tool City Grapeview County Mason C Deepening 0 Other lJ Dug ©Air- U Mud-Rotary Tax Parcel No. 22105-51-00078 Dimensions: Diameter of boring 6 iu..to 116 R. Was a variance approved for this well? 0 Yes LT No Depth of completed well 116 R. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread 0 I 0 6 in. a 116 .025 in 3 I 0 O I 0 Localism(see instructions on page 2) l3 WWM or 0 EWM 0 I 0 in in. ❑ i 1 0 1 0 SE r/.-'V.ofthe NW V.;Section 5 Township 21N Range 2W ❑ 10 in. in. O I 7 ❑ I ❑ C3 I 0 in. in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.341272 Longitude(Example'-120 12345) -122.964930 Perforations: 0 Yes U No Type of perforator used No of perforations Sire 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 in each layer penctrrated,.with at least one entry for each change of Screens: 0 Yes Fi No ❑K-Packer r- Depth ft. infcrmatb'n Use additional sheets ifuecessary Manufacturer's Name Material From To Type Model No Diameter Slot size in from R.to ft Brown silty sand and gravel 0 15 Diameter Slot size is from _ft.to ft Brown medium sand and gravel 15 19 Sand;Filter pack❑Yes L No Size of pack material _in, Brown medium sand and gravel,wet 19 26 Materials placed from ft.to_fr. Brown silty sand and gravel 26 64 Brown siltbound sand andgravel,tight 64 71 Surface Seal: Gs Yes Li No To what depth 24 ft Reddish brown claybound and andgravel 71 83 Material used in seal Bentonite Chips y Did any strata contain unusable water? U YesNo Brown silty sand and gravel,wet 83 94 Type of water" Depth of strata Multicolored gravel,brown fine to medium sand, 94 Meshed of sealing strata off loose,water 116 Pump: Manufacturer's Name Type: lI.P._ Pump intake depth'_Ii Designed flow rate- gpm - _ _ Water Levels: Land-surface elevation above mean sea level 220 ft — Stick-up of top of well casing 1 ft.above ground surface ---_ Static water level 56 ft.below top of well casing Date 2/15/23 Artesian pressure lbs.per square inch Date_ _ A;tesian water is controlled by leap,valve.etc 1 —_----____ Well Tests: `� _ Was a pumping teat performed? F.No 0 Yes . by whom? Yield gpm with ft drawdowr:after_his Yield gpm with_ft.drawdown after _ lire --'--- Yield gpm with_ft.drawdown alter hrs. Reeosery data(time n torn when pump is tuned off water level measured from well -" top to water level) Tame water Level rune Water Level Time Water Level Date of pumping lest Bailer test _gpm with ft drawdcwn after _hrs. 1 Air test 20 gpm with stem set at 100 R.for 1 hrs 1- Date 2/15/23 Artesian flow grin 'temperature of water 50 °f Was a chemical analysis made^ 0 Yes e,No Start Date 2/15/23 Completed Date 2/15/23 'WELL CONSTRUCTION CERTIFICATION: I constructed anti%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 Driller 0 Trainee 0 PE- Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 • License No 2874 - f�:r1'-- City,State,Zip Shelton.WA 98584 fI IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature _ Registration No ARCADD1098K1 Date E)CY 050-1-20(Rev MIS) ljtott need this(locum,ta in an alternate format,please cull the Water Reseurees Program at 360-107-6S7 2. Persons with hearing loss can call 711 for ll ashartgtm Relay Service. Persons with,a speech disability can cc:!!877-333-6341. I.-A Pre_ "11_,Jv ear_t' L,S.