Loading...
HomeMy WebLinkAboutWEL2023-00032 - WEL Application, Design, Letter - 6/29/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, , E 98584 SHELTON:360 427-9670, EXT 400 O. S,„ BELFAIR:360-275-4467,EXT 400 Ya� Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 PETERSON DAVID GUSTAV & ANNE LOURE IRETON 8405 DAWSON DR PLANO, TX 75025 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL 2023-00032 821 E Camden Way 120311290030 The 2-party water system, Peterson 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 4Nyt,:, Date Received: 1 _ �^ ' mor �, MASON COUNTY �)(,,/La, j . COMMUNITY SERVICES Amou \r h Building,Planning,Environmental Health,Community Health �• a 415 N.6'"Street,(Bldg 8)-Shelton,WA 98584 W E L 3 - 0 cd 3 2J Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE 1DAVE .+ AN/Q ?E-rereotil 9210-56141-5/0-75 MAILING ADDRESS-STREET,CITY,STATE,ZIP 9405 i`�A W 5v/1 Ty , rPz.AN o Tx r -750-Z , SITE ADDRESS-STREET,CITY,STATE,ZIP &1 I e- • C61i \DEnt 1-4AV , 64-1 1�cDn1 14A , qB &L1 PRIMARY PARCEL NUMBER(WELL SITE) IZ031 Jl -gO030 SECONDARY PARCEL NUMBER(IF APPLICABLE) WATER SOURCE - SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE til New ❑ Existing tg Well ❑ Spring II-7 I Alive PROPOSED WATER SYSTEM NAME(REQUIRED) 1- Z i`I ki PROJECT DESCRIPTION DIRECTIONS TO SITE/CONDITIONS rizor\& E-. 6OL- -)- )6A,-fo "Dz., 7 ►G>-V-r A--1" F. . +-1Azcc- Ata- S •, Fvt-w1.,1 ,t(,,t (1i9S► M4-,7" /N6?t ZATIUN L-J, rI t?orn►T+a) Ok{ E 3-? a(-r i-rc.- 1 AU -7-1 4" I\1 Air-J`J o i --ri2E.e• ThL r 4 ),A I M'D erz- ''I EZ E- SIN �� -1-0 Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) zi\t T op- +E Z A►7. i1--4E-Te / A L-i Y i 1-E "A" r Tz Awvg GATE Co`DE ►3 , 77-I-ENN'PrzE 3 'S'N-D L5-7 r"© . JUN 2 9 2023 By__ 4P JUN 3 0 2023 RECEIVED Submittals Checklist: (these additional items will be required for approval) L '\ 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) -1; 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: YES NO NA ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads within the 100 foot radius 9f the water source? If so, is road irivat- County or State. What is distance to ROW? 730— V6 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? ❑ The well casing extends l—? 4— above level ground/concrete slab? (circle one) IN ❑ ❑ Is there evidence of a surface seal? F. ❑ ❑ Does the seal appear adequate? OR "_. ❑ Is a variance necessary for well site approvvall?7 Comments ( ` - 1 D yD_ 7 i - ( -L . r5- _ Yg( Pass ❑ Fail Inspector Date ! (7'—�_ 7C_ Review Step 2: Two-Party Review: )2S NO NA ❑ ❑ Water Well Report with adequate pump test Ton file? If NO, date of Capacity Test 5/Z27 7j Driller ArCOdl"Lt l GPM 76 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test S�2 Z' ?Oz3 ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z(7 gI • (( ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer Date 7(ZO/ZO?3 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 i 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.con ...Where a o,r,enee manna (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample i County Collected 5 / 25 / 23 DAM Mason Month Day Yea • 4 - 00 la PM Type of Water System(check only one box) 0 Group A 0 Group B 001her Group A and Grcup B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Dave Peterson-821 E Camden Way, Shelton Contact Person:Arleta Eisele/Arcadia Drilling Day Phone: 360-426-3395 Cell Phone: Email: arleta@arcadiadrilling.com Eve.Phone: Send results to (Pont lull name.address and zip code or e-rrai:) arteta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION Sample collected by(name): Max Specific location where sample collected' Special instructions or comments: BPF087 Type of Sample(check only one box) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes❑ No❑ O Distribution System Chlorine Residual:Total __ Free __ Unsatisfactory routine lab number: 3.Scurce Ground Water Rule Sample ——_ __ S ` I Unsatisfactory routine collect date: CI Triggered Chlorinated:Yes ElNo❑ ❑Assessment Chlorine Residual Total, _Free 4. Enume'ation Source Water Sample I S ❑E.coil OFecal-Surface owi.springs Filtered Yes D No ED 5.Q Sample Cadected for Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory 0 E.coli present ❑E.colt absent Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑___ __- Bacterial Density Results:Total Coliform. - 1100m1. E.coli_ _ /100ml. Fecal Coliform _/100m1. HPC 11 ml. Lab ID Number �� rb1 SAY 16 0 t and Time Rece;ved. 2073 1(.a- Method Code: Date and Time Incubated: SM 9223 B Date Analyzed: /V l,/ Date Reported. ,744,A3 IIAY 17M ti5 DOH La Samples Lab Lse Only: 0 p'*331-319(e&aaaWO-If you and al;r110ica'.i0n in al a4mai ek,n3.ell e0a 5250127(MGM:a171r, het and otha gLbeabcra.o a.a hale a:wrn dcn saw adn,xryaafer 1 rt 1 7. . WATER WELL REPORT DEPARTMENT Of ECOLOGY Notice of Intent No. WE52046 Unique Ecology Well ID Tag No. BPF087 Type of Work: State of Washington CI Construction Site Well Name(if more than one well) Cl Decommission -..' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: 1 l Domestic ❑Industrial ❑;Municipal Property Owner Name Dave Peterson 0 Dewatering ❑Irrigation 0 Tcst Well 0 Other Well Street Address 821 E Camden Way Construction Type: Method: O New well 0 Alteration C 1 Urnen ❑Jetted 0 Cable Tool City Shelton Count) Mason ❑Deepening 0 Other ❑Dug O Air- 0 Mud-Rotary "fax Parcel No. 120311290030 Dimensions: Diameter of boring 6 io.,I. 171 R. Was a variance approved for this well? O Yes 0 No Depth of completed well 171 ft Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread N I El 6 in 0 166 .025 in. l3 I ❑ O I ❑ Location(see instructions on page 2): E3 WWM or O EWM O I O in in ❑ I ❑ IIII0 SW '/.-''Aofthe NE 'V.;Section 31 Township 20N Range 1W ❑ 1 ❑ in in. ❑ I ❑ ❑ I ❑ ❑ 1 ❑ in in DID DID Latitude(Example:47.12345) 47.184517 N Longitude(Example--120.12345) -122.852097 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 srrface 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: ❑Yes 0 No IE K-Packer (-- Depth 165 R information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works _.- Material From To Type wire wrapped Model No Diameter 5" Slot size.018 in.from 166 11.10 171 ft. Brown gravelly fine brown sand,tight,dry 0 26 Diameter Slot size in from ft.to R. Brown medium sand,dry 26 51 Brown sharp gravelly medium sand,silt 51 Sand/Filter pack:0 Yes O No Size of pack material in. bound,dry 53 Materials placed front ft to ft Brown medium sand,dry 53 61 Surface Seal: 57 Yes ❑No To what depth' 19 ti Material used in seal Bentonite Chips Brown pea gravelly medium sand,dry 61 78 Did any strata contain unusable water? ❑Yes E.1 No Brown coarse sandy gravel,moist,tight 78 94 Type of water? Depth of strata Brown clay,stiff,dry 94 103 Method of sealing strata otT Brown gravelly fine to medium sand,silty,dry 103 136 Brown fine tight sand,dry 142 153 Pump: Manufacturer's Name Type. Brown medium sandy gravel,wet,heaving,water 153 170 I LP. Pump intake depth: R. Designed flow rate. gpm Brown clay,stiff,dry 170 171 Water Levels: Land-surface elevation above mean sea level 116 IE. Stick-up of top of well casing 1 ft.above ground surface Static water level 110 ft.below top of well casing Date 5/22/23 Artesian pressure lbs.per square inch late Artesian water is controlled by (cap,valve,etc) Well Tests: Was a pumping test performed? O No 0 Yes c'=-) by whom? Yield ppm with ft.drawdown after hrs. Yield gpm with fr.drawdown after hrs. Yield ppm with ft.drawdown after hrs. Recovery data(time—zero when pump is turned otT—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 _i I Air test 30 gpm with stem set at 160 ft for 1 hrs Date 5/22/23 Artesian flow_ppm I Temperature of water 51 °F Was a chemical analysis made? ❑Yes O No Start Date 5/22/23 Completed Date 5/22/23 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 arc true to my best knowledge and belief 1C Driller 0 Trainee 0 PE-Prin m• y Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License Contractor's Sponsor's Signature Registration No.ARCADD1098K1 Date 5/22/23 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 71 I for Washington Relay Service. Persons with a speech disability can call 877-833-6341. ., {.d 1. 7 s-` _• 2198784 MASON CO WA x x , f �� a� � �ti x {,r :1:*.-- .) . s 4,'' -, �':..k: e 7'C i:; «� �-> 7,-1 ', 06/26/2023 01:35 PM NOTCE i' a z ytlK ,p r CURTIS HEARD *188141 Rec Fee: $204.50 Paees: 2 Return To -' t'�., '. -c'i IIII MIIIIIII11110111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII {' Tt s , Z1tt 'A ' �.v�. L/A 9 is, k Granter(s): (1) DAw:o G fbe-Me-S4 s-I (2) Grantee(s): (1) PUBLIC Legal Description(1) -at 8 S5 I0p4 ?ridov 'I,--o (Abbreviated form:i.e. lot, block,plat or section, township, ; ,, .' 2 03 1 - 1 2 -`�` 0 d:.:3Q. Assessor's Tax Parcel: (1) v NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYS i I (We)the undersigned grantor(s), certify that the water source located on the above-d 1 real estate under Legal Description (1)and Assessors Tax Parcel(1) situated in t , , .L County, State of Washington, has been designated to serve a source of water to the fa* ' .- parcels situated in Mason County, State of Washington; herein described Tax Parcel: (Connection 1) 1 `' - 2-1 Tax Parcel: (Connection 2)• J 2-Q 3_L-_.L Z- 9 .00.s The system owner is responsible for keeping this system in compliance. The name of the water system is: 'P.TfG.R$o,4 Z V "Y V4,1 E,L 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 ser9rices. I 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. �7Z�Q +,�J Dated on this G day of �1 e= , 20 Signature of Gra 9 I" 4 (1) ®4'' %Y . f"';" .._,r ... J?as.:rs&3s.;t..iC ' 7 i.:: I-- " . .... - n • :x � `A.�i r7 "�.d `•F• .. `t `..��F iq/X a . ) i' ti c 4 i ! AyJ+g �.' r t il./A .;�2' . .,'tr• ��I�'Cs " em f "'� 1am ,- 1. f4�x���4 _f f State of.VAS F4 , TM County of • I,the undersigned, a Notary Public in and for the above named County and State, do hereby • Cart ify.that on th)s 22• day.of )c, , 20 Z3 , 0<ia 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. Notary Public in and or the State of yv AhWRI ALONZO BRUNO GARZA ,r• =/ ID N133153326 residing at �� Notary expires: s.1T ,?7 My Commission Expires My commission exp' o.It. June 11, 2025 • r "•.. • • r �! v y •�,(i r"" ;�t t j1�'9'Y.-.f f'�„'r 5✓1 ` t 4 _',; - s t 1y s f . + f c .1. C$� t , st �r, � t ; 1 e � of , 1 I I I I 1 7 4\ v 1 1 7 IE ! 'if1111 . 11 . 1111 hi 1 1 q 1 1 i i 0. ii: $ l''' 124 ; i ! ; 1 ! R ; ; : 1 11 1 1 1 ! i ri ! 1! I i : 1 ; lill 1 I ! 1 ; 1 g 1 1 / 2 1 1 ; i ! i 1 1 ; ! ! 1 Pi R 1 _ 1 I 13. li i '-! ; i 1! 1 i 1 Qo g I I : i ..! i : 1 - . .'.__• - - - _. _ _ P.L, N 1d51'17" E 151,17 FT P 15'FRCAT SETBACK_ -- ' 1 7 I N R I I 0_ — :'- "'...En -I • IN. \ % '#, // ** \. 4 it 1 i/ \ 1 �c / -$.� t I I 82 I M C,=1 1 i 1 0 z m N �A ice— 3 - —__ —�1 G ; U �` rM �„I I ,� -__-'- :: / (1.1/ // / / -`N' s-1 \• \ / r fn /� - 1� ,y N II 'T7 m lJ /NJ Cn c.,,,. ` _per" 1 \ , _ . , , ,,. _ , ,...„,,,, ..._____.7 4- , ,,, U S. • - ', �' \ `\IBC 4 JJ gil \ \ --_-,--7,..- _--.„...--=- .,:-.c-i, -7.-- / '. ' ii`tri ‘• 1 Vie'`- ksF sernc acumc era.iza]\ (1....\\ zy' \\. �lEPIICpIrN11Y ��4.. 1 •\\ �\ �'"'tgyC • __ , — _ inal V \-' li 'IL\.' �-..- \ .r , _ \ter ..( \\ • • \ �\ \ is \ --.. -- -• . 4 \ •. ,I , \...... , . .. , ......._. .... .. ..... ...., .., . ._\ A .. \ \ . . \ • � �".\�\\\ \ \\ \ \\ \\ \ \\ \\\ . :-I. ffI \ \. \ ••••-_,__ .1. _. .....,:.... ...„ ...„........„ .........,,. , . .... .............„_.,..,,,,....., ,,........„. „ , , ,),,. .., _....... ........, ,.... ., :...,......„,„_,....„,.,:....1 ,...,...,.... . s. .. _... .... .......-„_, ,�/// tip`--�` �\\\\` \``\ . •'�'' \ �.. �i,` --.,s,} ` �\ .--25.._ �\\_I_- I-- -1-- s. I— PETERSON RESIDENCE 1821 E CAMDEN WA VI VI a p _ f i III! !! PROJECT#; 21-PETE-153 SHELTON, WA 98584 ���� o � � PHASE 2.0-PERMIT SET j TAX PARCEL#: 12031-12-90030 R!ii 1411 II II: 3 i(-- c.r , IllboNe.... \ z...\e......VStr. . -..\ Q._1,\___. :c: 1._sci,\-- __A - \ .(YIN- \` ,- '\0() C) 7g. \..k. , 2,; 7\__\ -1,, _,.\ sCf)ZA. a-.r\- ,D ":c11/4 , \NCC-\.., 'r--- 9'0 kf\\ --,•-•••c..0.,\Q., • ' Air 0 iSc VI f , • 1` i� z A + 1 6). 5't'.1%14 V.,;`® DALE L. 7 • •L1rr'.i5ft r ESIGfvER it EXPIRES: -- -b. - `' 4-6t` i H G \ c 1 y Jet:�.3r\. =� (1-s '.r(---.}) cki. r ' t� ! 0 `'-E ti �' `.1.3 c5 E C ce cN--- . ,..-•-• ---ic.; 04,i'.i tY - . .. . - 6 . .•__ - ... .-- --- 41) Y - �i :I' . 2• ` t "L C' '�`' .r 4 • ________ ....„ . .... 4PPROVE ,. ,...... , .... , c 2 ,...._. ,,v rFEB r, 1R9NA4E202 ...., Jgvv N. S � S r it^l °' k 4- ; ,,- . - o, �� r . `I 1 Cn/ . - r fn 'CO '_ A (41 il 11 / e . . - -,11./. . 0 t # o ci • i �t1. 4 0 •1 1 ""a} I U/Il 1 // o S "I r a � ` ` , .0 d.i I , .411___. Coo <:�r, „ 1 ,,0