HomeMy WebLinkAboutWEL2023-00033 - WEL Application, Design, Letter - 6/27/2023 • MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
,..-� Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
William Giese
221 NE Haven Lake dr
TAHUYA, WA 98588
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00033
190 NE Haven Lake Dr
223305000300
The 2-party water system, 190-180 NE Haven Lake, 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
i
•
Cift- MASON COUNTY Date Received (o 1.
3 COMMUNITY SERVICES .:�nndntRe r�ed
_ - Receiveg8�..�.-
\•',, ;i'�' Rrnlding,PLtnnmg,Envranm.ntal Health,(.omrmmnyHealth
tr{`�jD,
"'n,IYt\.:
415 N.6°i Street.(Bldg 8)-Shelton.WA 985S4 W E L )-3 — U L0-
Shelton 3A(I-427-9670 x401) 13ellair:360 275-1467 e4(1(1 lima:360-482-5269 x400
TWO—PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT
WILLIAM GIESE PHopE60-801-8085
MAILING ADDRESS-STREET.CITY.STATE,ZIP
SITE ADDRE S�SN T. AV ENtPLAKF_OR, TAN U YA, WA 9R588
180 NE HAVEHN LAKE DR, TAHUYA, WA. 98588
PRIMARY PARCEL NUMBER(WELL SITE)
22330-50-00300(190 NE HAVEN LAKE DR)
SECONDARY PARCEL NUMBER(IF APPLICABLE)
22330-50-00300(190 NE HAVEN LAKE DR)
WATER SOURCE SOURCE TYPE
New psExistinrt PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
��'ell ❑ Sprin�� 111 . 6 S- �+
PROPOSED WATER SYSTEM NAME(REQUIRED [Qr
!fD- WO EVE !jreel La(q.
PROJECT DESCRIPTION
o `f �..) C,c Sc) .,y
ile i
DIRECTIONS TO SITE/CONDITIONS J
GO INTO BELFAIR,TURN LEFT ONTO OLD BELFAIR HIGHWAY.TURN LEFT AT STOP SIGN.GO PAST STATE PARK.TURN RIGHT ONTO BELFAIR TAHUYA RD
GO TOWARDS HAVEN.(HAVEN S LAKE WAY).TURN LEFT ONTO HAVEN LAKE DRIVE.PARCEL IS ON LEFT SIDE OF ROAD.LOON STEEP DRIVES.WELL
HtAU IS EitNINU I Eft HUUShU
Site Plan: (may also be attached)
(properly boundaries,structures,well site w/100'radius,driveways. roads,septic/sewer components and lines. easements.etc...)
r 1 IT JUN 27 2023
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
�`-� "-- ---Staff Use Only
Review Step 1: Well Site Inspection:
•
YES NO NA Path+ &i I lawIHwwer, alt►t(i(taIs ell ck 99e St-n tf k(1 tAtoel
❑ ❑ 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 of the water source? If so, is roe. riv. •, Countyor State.
What is distance to ROW? Df.'lAtvGy r P
X' ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ Is the well cap satisfactory? ZOO- S A0t/1/ //OS (o
❑ Screened and vented? j�
M The well casing extends '/ Z 6 k above level ground I concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? ��� r,�/ ys(Z�6y
❑ ❑ Does the seal appear adequate? CO/ -!
❑ ❑ Is a variance necessary for well site approval? (LZ,reS�-727
Comments
❑ Pass ❑ Fail Inspector 77fl/t?GZ3
Date
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate//pump test on file?
If NO, date of Capacity Test_f /3C/zof l Driller Oiv'S Print GPM LC
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 7/(7i/(!JZ1
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2f,r6.757
❑ ❑ System appears adequate to serve 2 single-family residences based on informati r ?
Comments —_ w `
•
4f4Savn
000
14411
Approved ❑ Denied Reviewer Date ( 770t§/8POHy'F/�lq
C
I.hidings in this review reflect observed conditions as they existed on the cloy of the site inspection. \o quint is made, express
or implied o/the Attire success or jailure of this system. Hell site approval does not constitute water syvlent approval. II'ale r
.S1'sient cy>//royal is a hrn-pcu'l process.
.111 proposed connections to new wells are subject to water adequacy requirements at time of building permit per rl/(Y'6.6h.
lithe!.usage restrictions erne/additional lees may apply to all nor wells drilled a/icr Jcumurr. 19 r 201 R per/:S'S/3 609/.
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/I3/2021
Page 2 of 2
Thurston County Environmental Health
2000 Lakeridge Dr.SW m Olympia,WA 98502
; , i 360 867-2631
TIHURSfON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
^ ' !7 I �2 Collected
D ` 3 2 . P" /V��s014
Moat Day Year V,
Type of Water System(check only one box) ❑ Private Household Mai,
❑Group A ❑Group B ` l��tl.OtherslE F Mu !
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:77At 7: ,STEARg
Day Phone:253)S?9-- 4bt3 Cell Phone:( Sao,e/
E-mail-imp c,fAro,f Eve.Phone:( 5a.me
Send results to:(Print full ame ddreljand zip code or email address)
SAMPLE INFORMATION
Sample collected by(name): 717?i n:pE4-
Specific location or address where sample collected: Special instructions or comments. T
gito E•Ftt4soii LAKE ptinns. Papvtst
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
0 E.coif-GWR(AP)
❑Fecal-Surface,Owl,springs(nornerat.onj Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S
4�Sample Collected for Information Only � I n /,,,;,�.
Investigative Construction i Repairs Other .o/` f
oit
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
oliform detected
❑E.coli present IDE.coli absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli __ _/100m1.
Fecal Coliform /10Dm1 Enterococci_ _ /100 ml.
Method Code:'SM 9223E ❑SM 9222D Date and Time Received: k..)
❑SM 9215B ❑Enterolert0 1- II—Z-3 (6Ic
Date and Time Anatyia�•
\ 1• - — Date Reperted:I J e/f�
Sample Number(DOH numbe•plus Eve uiiVs) //f Lab Use Only:
0 8 0 3 88 '
DOC qm a33,.3,s`eO 2 r17,�, ' sS—
•
.
•
•
611 WATER WELL REPORT is
wwr ,a•
KO rwY Original&f copy-Ecology,2"copy-owner,34 copy-daWm CURRENT
Construction/Decommission(V In circle) •
Notice of Intent No.W 249650
Conduction Unique Ecology Well ID Tag No.BAC 501 F
Decommission ORIGINAL INSTALLATION Water Right Permit No. i
Notke of Intent Number I.
PROPOSED USe3 ®pomade Q tadsemil DMosidpsl Property Owner Name Ken Glees
4� 0 DWWarr 0 Intake ❑Tea WaIl ❑cow Well Street Address 190 NE Haven Lake Dr. I
ne
TYPED/WORE:Oam umber mber dwell(if men ttsa e) •
City Tehu
CI ❑Recoadltimed Method: 0 Des ❑Bored 0 Driwe County MasonMasonNew well
O Decpm•d (J cable Ottogn 0 lama , LocationNS1�.1/4-1/4.$..K.1/4 Sec Twn23 R me 0 check
Ol WAOtIS:Draperdwell 6 2S3or
n.ea well Ice d<'v'd it' (a,t,r Still REQUIRED) Q One
CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Mia/Sec
• �,a ❑"Welded 6 • D .from+4 t a 2!4$-_. ft.+n.er ❑Lime Inr.uoa • Dam.from fr_a Long Deg - Long Min/See r
0newdoa • niam From t to t Tax Parcel No.(Required) 22330•50-00300
PadoesWeas D Yes 0 No
Type of mama midm+ COMSTRU 1ON a
oe DECOMMISSION rRoMRte
Foedoa:Deseetbe by orator,dractse.size of material mad gramme,ead the&dad sad !
Sam of part 'm.by its.ands).of path tam t to R. sere of der msedW In rseh atreloe paoearated.with rleeaqass may rbr sorb dye
Sas�err QYm ❑No OK-Pao Location Zdb — of fin, ..(USE ADDmONAL SHEETS IF NECESSARY.) i.
MraimsmfsNae JOIMS012 MATERIAL FROM TO `
Typo stainless Model No. OM RE0 75 P
Dina.5" star sitsPine tame send a silts wills water 75 IOS
16 Rom 248 t to 253 a: i
Dims. Stet is Rom a.a t Cemented tend t gravel with water 105 _ 175 •
OrmNNFRterpadet 0 Yea 0 No Sim asn.Woo or .Brows till 175 249
M ia1a pima Rom tt to t. Sand&gravel with wooer 247 253
sttatlsatert: Qr Ys ❑No To whit depth? 35 E.
Menial sod to asl Bttomite 1,
Did soy ores media unable yard! 0 Vs 0 No t
Type of wage Depth of strata r
Method aimless male of '
i
PUMP:MaufaaturatsNee
TVs: H.P. i
i
WATER LEVELS:Lard srece alsvados above meta sea level t 1
Static lard 220 E.below cep dwell Date I
, r
Artesian
presto- nee.per r pue loch Date t
Adidas water controlled by {pp,valve,eh:.)
. WELL TESTS:Drwdowa is ameast water level a lowered below steno level
Wu a ram tut made! 0 Yes p No Ur',by wham? i
Yid& *Ada.with A.drawdowe attar Ms.
Yid& slimes.with a.d awdewe dbr hum
Ytdt pLlmio.with t.dmwdoam atar by"
l cneeryAato(time token m awn when pump tamed off)(teeter level measured ham wed !
tapattatrkVra r
Mad Warr level Tare Water Level Time Water Level i i
i
i
Dole of rat a i
Mir Tag 15 pl.ho.Le.with S ft.drawdown after l Iva. i
Rae
i
news puede.wesr et I.
b a let thr n. t
t
Anon Bow ' Nos Dols i
Amnon
Temporisers adder Was a Gimbal mlyW made? 0 Yes 1)No Start Date 11/24/10 Completed Da.e WWII !
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well f
construction standards.Materials used and the informati reported above are true to my best imowledge and belief.
0Drdk(0 tti�Frgi0 Trainee Name .a Mike is Drilling Company Davis Drilling !
Driller/Engineer/Trainee Signature' e — Address 340 NE Davis Fenn Rd.
Driller or trainee License No. 797
IF TRAINEE:Drillers License No: City,State,Zip Belfair WA 98528
Drillers Si Contractor's
: Regisaation No. DAVISDII 100A Doe Jan.2011 i
i
pthe Water Resources Program at 360-407-6600
i ■ E e e t)i with a speech disability taint calf 877 833 6341.
Printed from Mason County OMS
2199618 MASON CO WA
07/17/2023 02,33 PM NOTCE
WILLi IIIII0IIIIIII I 1 ANAM 5 11 i1Otl UII I� III III 01II I0110II11 IIII I E 116E1822 Roo Fee, S204.50 _. 2
Return To
WILLIAM GIESE
221 NE HAVEN LAKE DR aRM
TAHUYA, WA. 98588 •
JUL 2 8?023
RECEIVED
Grantor(s): (1) NETTIE ALLEN , (2)
Grantee(s): (1) PUBLIC
Legal Description (1)Tr ,ct 30O of- L{s1(tr-t
(Abbreviated fern:i.e. lot. flock, plat or section, township, range)
2 2 3 3 0 5 0 0 0 3 0 0
Assessor's Tax Parcel: (1)
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) 2 2 3 3 0 _ 5 0 _ 0 0 3 0 0
Tax Parcel: (Connection 2) 2 2 3 3 0 5 0 0 0 2 9 9
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 II day of 3 Ulj , 20 .
Signature of rantor(s): / I� A
(1) `� ,� X , (2)
v
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 LU day of 3.c,.1 c, , 20 2,3 .
4UG� 2 g-tt ersonally 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 for the State of Washington,
residing at lLI c&%J ✓
My commission expires: •rivf P �5( 2021
'ta�uuniruw
Kfki
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Page 2 of 2
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