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HomeMy WebLinkAboutWEL2023-00035 - WEL Application, Design, Letter - 6/28/2023 • MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584 SHELTON: 360-427-9670, EXT 400 BELFAIR:360-275-4467, EXT 400 ik14Public Health & Human Services ELMA: 360-482-5269, EXT 400 as FAX:360-427-7787 Doug Devlin PO Box 367 LILLIWAUP, WA 98555 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00035 XXX N Shar Ln 323165000022 The 2-party water system, The Old Farm, 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 t,. Da te Received MASON COUNTY (o Q g, _ , COMMUNITY SERVICES Amount e. _ Receiv k / Building,Planning.Environ mental Hmlth,Community Health 415 N.6i6 Street,(Bldg 8)—Shelton,WA 98584 W E L a 6 ) :?)- Co(D 35 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION AP PLICANTT___/ PHONE /�'? 4Zfi',e vi7 /),ayVJ(/a 3& -�pd - 4/�eMAILING ADDRESS- E ZIP � ,0 goy _36,7 SITE ADDRESS-STREET,CITY,STATE,ZIP L.�I'(mod UP �� 7g 5�5 XXX U. Shay G✓� PRIMARY PARCEL NUMBER(WELL SITE) 3 d 3/ - v - coo a)- ( J.iii,¢e4 -e-606=d do,;/3 000a 8 SECONDARY PARCEL NUMBER(IF APPLICABLE) 3a3/(- Sb-- ocx)Z_ 1/, 7(I/54F7/.2 �Q WATER SOURCE • SOURCE TYPE • I PARCEL 1 LOT IZE PARCEL 2 LOT SIZ� New 0 Existing %Well 0 Spring I Va2e9�_ ,a(p d PROPOSED WATER SYSTEM /NAMEEOUIR�) _ ,AA �'�'`-7� I Ir 3 25.5(�l — PROJECT DESCRIPTION_( /Y'/^1' Cf/I (/_l/ ,V�' /a 76 - r14 /--ae),1o, -/ tiell 2C/ 6Vs as )L- a3 DIRECTIONS TO SITE/CONDITIONS "Ide ��% it y / / A)047/4 16 .S`dZ Z, a /,er,. o,i ' /. y74, Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) ,__6e,a_ /714 i/- JUN 3 0 2023 JUN\2 S 2023 [fi _. (EMWIE --1 RECEIVED 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) tl/ 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: Dot �a, C�— e 6 V Sc i YES NO NA 4 a kC.,A t4v ❑ ❑ Evidence of existing sources of contamination within 00 foot radiu of water source? (drainfields, tanks, buildings; indicate distance on plot plan) `f'', ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road privat: County ,.r State. What is distance to ROW? 4 V ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) y', ❑ ❑ Is the well cap satisfactory? RE, ❑ ❑ Screened and vented? i i ❑ The well casing extends "- above evel groun• /concrete slab? (circle one) LI ❑ ❑ Is there evidence of a surface seal? 1.1.. • ❑ Does the seal appear adequate? OF ❑ Is a variance necessary for well site approval? Comments ))P 1—vQ 6 Pass ❑ Fail Inspector Ci 6t4,6 f-J,LAlh, Date ( 1 ,Z Review Step 2: Two-Party Review: AYES NO NA f��'( ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 50 70Z. Driller fittOr(ICE '(t f'41 GPM x pfs El ❑ Received Satisfactory Bacteriological Analysis? Date of test 6/l/Z07/ ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z(Q 8g86 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer Date 700/Z Z j 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 ,1`=�-i DEPARTMENT OF Notice of Intent No. WE52201 WIECOLOGY Unique Ecology Well ID Tag No. BPF006 Type of Work: State of Washington Cl Construction Site Well Name(if more than one well): ❑ Decommission c==l) Original intallation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Douq Devlin ❑Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address Maple Lane Construction Type: Method: P]New well 0 Alteration 0 Driven ❑Jetted 0 Cable Tool City Lilliwaup County Mason 0 Deepening ❑Other ❑Dug ©Air- 0 Mud-Rotary Tax Parcel No. 323165000022 Dimensions: Diameter of boring 6 in.,to 235 ft. Was a variance approved for this well? 0 Yes [1 No Depth of completed well 235 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread © I 0 6 in. 0 235 .025 in. © I 0 0 I Cl Location(see instructions on page 2): ©WWM or Cl EWM ❑ I 0 m' in. ❑ I O ❑ I ❑ NE 1/4-IA of the NW 'A;Section 16 Township 23N Range 3W ❑ I CIin. i _ in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.490976 Longitude(Example:-120.12345) -123.077297 Perforations: ❑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 in each layer penetrated,with at least one entry for each change of Screens: 0 Yes 0 No ❑K-Packer b Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size in.from ft.to ft. Brown silty sand and gravel 0 5 Diameter Slot size in.from ft.to ft Brown silty clay 5 11 Sand/Filter pack:CIYes III No Size of pack material in. Brown silty sand,few gravels 11 22 Materials placed from ft.to ft. Brown sandy silt 22 38 Surface Seal: 0 Yes ❑No To what depth? 18 ft Gray silty clay 38 78 Material used in seal Bentonite chips Gray sticky clay with lenses of gravel 78 107 Did any strata contain unusable water? 0 Yes ©No Black gravel,silty,lenses of gray clay 107 112 Type of water? Depth of strata Brown silty gravel,some fine brown sand 112 169 Method of sealing strata off Brown silt 169 174 Gray silt 174 198 Pump: Manufacturer's Name Type: Gray silty clay 198 210 H.P. Pump intake depth: ft. Designed flow rate: gpm Gray sticky Gay 210 214 Water Levels: Land-surface elevation above mean sea level 200 ft. Gray silty clay with gravel 214 222 Stick-up of top of well casing 1 ft.above ground surface Black gravel,brown medium to coarse sand, 222 Static water level 140 ft.below top of well casing Date 5/18/23 Artesian pressure lbs.per square inch Date water 235 Artesian water is controlled by (cap,valve,etc.) --- Well Tests: Was a pumping test performed? ©No ❑Yes c 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 20 gpm with stem set at 220 ft for 1 hrs. — Date 5/18/23 Artesian flow gpm _ Temperature of water 49 °F Was a chemical analysis made? ❑Yes 0 No Start Date 5/18/23 Completed Date 5/18/23 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—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature !� / Address Box 1790 License No. 2874 City,Statee,,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 5/18/23 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. Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 y.ROQoaaD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 06/01/2023 Corected ❑AM Mason CO Monthoay Yea 3 ®PM Type of Water System(check only one box)❑Group A 0 Group 8 I Other Pv T 061 Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Doug Devlin Contact Person:Arcadia Drilling/Arleta Eisele Day Phone:(360 )426-3395 Cell Phone:( ) Email:arteta©arcadiadrilling.com Eve.Phone:( ) Send results to:(Print full name,address and zip code Of e-mail) arteta@arcadiadrilling.com AND sue@arcadiadrilling.com SAMPLE INFORMATION Sample collected by(name):Seth Specific location where sample collected: Special'instruction or comments: #BPF006 Maple Ln, Lilliwaup Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A/P) Chlorinated:Yes No (from distributon system after unsa.routine) Unsatisfactory routine lab number: ChlorineResidual:Total Free 3.Ground Water Rule Source Sample S ( I Unsatisfactory routine collect date: I / Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual.Total Free_____ ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) IS ❑E.cos ❑Fecal Fdtere Yes_NoJ 5.0 Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and $Satisfactory 0 Ecoli present ❑E.coff absent Bacterial Density Results:Total Coliform /t00rn1. E.coli_ /100ml. Fecal Coliform /100ml. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ oaterrime Received: tab Reference Numter (o/zI t3 1( :ZLD . VLS4462-9 Receipt Temp C: f!e71od Code: 6.0. C. Sf'1R223B Date Reported to DOH Lab Use Cr.y: DOH Lab-Sample* 285- DOH corn 1331-219(..ek917)-a tai iteo Sn pace_ranan a ar are brat at 525 Ott)(TL'.YrrY at 711) Thew!etw rztattore an m7aCba1 mei aon h Sro.:dr.rk q•Me 2198886 MASON CO WA 06/28/2023 10:58 PM NOTCE DEVL N Return To ,� III II 1III11iII 1111111111111III 11 II II II111111IIII11111III11I 111. 2 7) so// 6,)c .67 ll; rv'afi, /Al✓t 11 . Grantor(s): (1) DiEJej/ S// /J10/, ,l , (2) /0 I l Grantee(s): (1) PUBLIC Legal Description (1) SL=C`6 t u) A) 02iA1 R3(2) WO L740?,g, (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 3 R 3 / - U 02 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 2 3 / `;0 Tax Parcel: (Connection 2) Sa 3 ,' ti - 6Q - Q 0/ 3 The system owner is responsible for keeping this system in compliance. The name of the water system is: 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 // day of , 209 nature of Gran or(s): (2) Page 1 of 2 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 2121 day of dUrlia. , 20 2 , TitxUg\aS -VV.1-, 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. KAELI MCAULEY Notary Public Notafy Public in and for the State of Washington, State of Washington residing at 526 kJ Ci2.40r S Q(#-on,LA.)a License Number 22037380 My commission expires: c antzt('y 20) 202`7 My Commission Expires January 20, 2027 Page 2 of 2 m ` • 1 ! i . \ 1 'h n. 0. _ 0 I. \\ i \ to , / 1 \/ • • / \.73 . tC I. ti a t E '1 `' S. / • +o liCi cx 1 4. N i V./K 3 A f -I \ I , i i 4 / PT I i �f d / O, • t f i yy H i i in Nllb'3N 1�113wN0��A'�?,�1hn 00 NOSbW N a. fdnf a3At„j o p o -a �. a to +� 4 \ M .p .s • r� -- - k/