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HomeMy WebLinkAboutWEL2023-00036 - WEL Application, Design, Letter - 7/6/2023 MASON COUNTYn. 3 415 N 6TH STREET, SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 , .44._.,,.,, BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA: 360-482-5269,EXT 400 FAX:360-427-7787 GOULD DOUGLAS LEE & ROBIN LEE 841 EAST CAMDEN WAY SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00036 841 E Camden Way 120311290010 The 2-party water system, Camden Way Two-party, 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, Da idlanderson Mason County Environmental Health f""'"I , N Date Received MASON COUNTY ''l (o . e)..."-j . ( •11 :, COMMUNITY SERVICES Amou Rece y � ' ' .� �C Building,Planning,Environmental Health,Comrnunity Health 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 WE L `),v 2 _ Q(_Q Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE DO t,kgk5 ' �iobin 610 61 2.53- ant-755S MAILING AD ESS-STREET,CITY,STATE,ZIP i E. Ca►ncOen Way 6he I1-on, NItP 9g5g4 SITE ADDRESSt -STREET,CITY,STATE,ZIP / Si i 1� ` n ,A I-1 i E. Cttmcie'n \(11 Gky She 1 fron, W i D sco PRIMARY PARCEL NUMBER(WELL SITE) ( 2,03t— t .- - 9oo(D SECONDARY PARCEL NUMBER(IF APPLICABLE) 12D3t - 12 - 9 abso WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE Cl New G&[xisting fyi.,\Well ❑ Spring t,(9 Ct_er---. 1 . z(c, tic_c e.5 PROPOSED WATER SYSTEM NAME(REQUIRED) C_amcder) kf ax Mr° - kfy PROJECT DESCRIPTION 1 Sh0.vQ/ 1111z .Ut berVi0c'A� 0 CCh 1tylo Jf'op€ tIC.S DIRECTIONS TO SITE)CONDITIONS Cr'o5S lActie,,-trie, klarvk brirty. R1- br4r' Sou.t-h lslat l -114ve . A+- Turn }bArn 611,n4 ov1ry I-tarsh're. tsinni -gDo,el cotAfil for r1/2 bile, r Leff an Cast- CAm i,l,rny. Call c f key Pack q z cede . -kilo J t- Ccvnde-. Limey - -1,-;.rn leFi- en 34{-( Dr= kre.t e y Site Plan: (may also be attached) D SW n 14;It V,1 e.c, d Vn k t9ht (property boundaries,structures,well site w/100'radius.driveways,roads,septic/sewer components and lines,easements,etc...) �W JUL 1 2 2023 t L JUL 0 6 2023 Submittals Checklist: (these additional items will be required for approval) fgf Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) ET Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) it 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 I. --------- Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ 171 ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) SK ❑ ❑ Are there roads within the 100 foot of the water source? If so, is roa privet County or State. What is distance to ROW? U g. ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) lap ❑ ❑ Is the well cap satisfactory? '`fl ❑ ❑ Screened and vented? i‘. ❑ The well casing extends 2 above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? TIC ❑ Is a variance necessary for well site approval? Comments • Icb [ 3 3 l _ tom- ,TS--2 Pass ❑ Fail Inspector ( Date `7 t 3 .-5 b� Review Step 2: Two-Party Review: YESX NO NA ❑ ❑ Water Well Report with adequate pump teston file? ,.,,� If NO, date of Capacity Test 77 r( 7071 Driller IC'C4u1 /Or//�(�') GPM ? 0 � ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test (�4"( ?OZ.V /❑ ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2Z001:578 X ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments ;Xi Approved ❑ Denied Reviewer412/—*'. Date 7 3// -1 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 no!constitute water system approval. Water System approval is a two-par!process. .Ill 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 S tTe. PLAt4 EAST CAM,DE.v t way oe o W A arb3I- 7i Rcoce, S C ! N 6 V a M SEPT c ?Rs POSKO F' \ V xP3 EASEMg•NT 100' WEAL ' PRoPERr�/ X ""` PRoPEeTy £ MTA,“ r E.ASa:ri%N r ({1. 2 IZo3l-�2-9aoro I SEPTtG } APR RaVED I i 32' WATER WELL REPORT t- „5,: ,:1 DIPARIMINI Of Notice of Intent No WE43401 iiiiiiii ECOLOGY Unique Ecology Well II) lag No BMS072 Type of Work: State of Washington O Construction Site Well Name(if more than one well) 0 Decommission er__. Onginal installation NOI No. Water Right Permit/Certificate No Proposed Use: RI Domestic ❑Industrial ❑Municipal Property Owner Name Doug&Robin Gould Cl tewatcnng 0 Irrigation ❑Test Well U Other Well Street Address 841 E Camden Way Construction Ty pc: Method: 0 New well 0 Alteration O Drisen 0 Jetted ❑Cable Tool City Shelton County. Mason U Deepening 0 Other U Dug Di)Air- 0 Mud-Rotary Tax Parcel No. 12031-12-90010 Dimensions: Diameter of boring 6 in,to 178 ft Depth of completed well 178 ft Was a variance approved for this well'. ❑Yes a No Construction Details: WallIf yes,what sans the variance fort Casing liner Diameter From To Thickness Steel PVC Welded Thread • I 0 6 in () 174 0.25 in LI I 0 EC 1 0 Location(see instructions on page 2). [_4 W W,Y1 or 0 EWM ❑ 1 ❑ in _ in. ❑ I ❑ ❑ I ❑ NW %-%of the NE V.;Section 30 'township 20N Range 1 W ❑ I 0 in in ❑ I ❑ ❑ 1 ❑ ❑ 1 ❑ in _ in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example'47 12345) 47.184599 Longitude(Example.-120 12345) 122.852580 Perforations: 0 Yes ni No Type of perforator used Na of perforations_ Size of perforations_in.by_in Driller's Log/Construction or Decommission Procedure Perforated from ft to_II below ground surfaceFormation 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: Is)1'cs U No fit K-Packer - Depth 172 it intormation Use additional sheets if trccvary Stauufactwer's Name Alloy Machine Works _.._ Material From To Type Wire wrapped Model No Diameter 5 Slot sire.016 in from 173 ft to 178 ti Brown fine sandy gravel silt bound,tight,dry 0 18 Diameter Slot size_in from ft to n Brown some gravelly fine sand,tight,dry 18 38 _ Sand/Filter pack:U Ycs No Size of pack material in Brown gravelly fine sand silt,bound,tight,dry 38 69 Materials placed Gum R.to ft Brown fine to medium sandy gravel,sharp, 69 tight,dry 90 Surface Seal: G7 Yes n No To what depth" 19 ft Material used in seal Bentonite Chips Loose medium sandy gravel,wet 90 102 Did any strata contain unusable water? n Yes 0 No Brown clay,stiff,dry 102 112 Type of water"' Depth of strata Brown fine silty sand.dry 112 143 Method of scaling strata off Brown fine sandy sharp gravel,tight,dry 143 149 Brown fine sand,wet.tight 149 156 Pump: Manufacturer'sName Type Brown gravelly medium sand.heaving,water 156 II P._ Pump intake depth" ft Designed flow rate gym bearing 174 Water Levels: Land-surface elevation above mean sea lead 143 ft Brown course sandy gravel,heaving,water 174 Stick-up of top of well casing 1.5 ft abuse ground surface bearing 178 Static water level 119 ft below top of well casing Date 7/7/21 Artesian pressure Ins per square inch Date Artesian water is controlled by (cap,sake,etc) Well Tess: Was a pumping test perfumed' Ell No n Yes c.-,, by whom" .... Yield gm with ft drawdown after has Yield _gpm with ti drawdown after his - Yield ppm with ft drawdown after hrs Recovery data(time-zero when pump is turned off water level measured from well i top to water leach Time Water I.cyel Time Water I earl late Water I esei Date of pumping test Bailer test ppm with_ft draw doss it after his Air test 30 gm w lilt stem set at 160 ft for 2 bra — Date 7/7/21 Artesian flow gpnn _ Temperature of water 51 "F Was a chemical analysis made^ 0 Yes Ei No Stan Date 7/6/21 Completed Date 7/7/21 NVE1.1-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 0 Driller 0 Trainee❑PE-P- 'a •Roger Phythian Drilling Company Arcadia Drilling Inc. Si •ture Address PO Box 1790 License No. 2053 City,State,lip Shelton,WA 98584 IF TRAINEE.Sponsor's license No Contractor's Sponsor's Signature Registration No ARCADDI098K1 Date ECY 050-1-20(Rev 09/18) If)vni need this document in an alternate format please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 7l1 for►Pashingron Relay Service. Persons it'll/I a speech disability can call 877-833-6341. Thurston County Environmental Health 2000 Lakeridge Dr.SW !Olympia,WA 98502 � 360 867-2631 THURSTON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected �' I 2-3 :20 0PM Mk`�� Month Day Year Type of Water System(check only one box) 0 Private Household ❑Group A ❑Group B Otherrwo ?A,RTy Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: Rpg 1 14 Goa Day Phone:(25 3)30(._-is S Cell Phone:(1.,53 E-mail: ) _ `�'� � �Dbtrlde&l911Sp_ho±r a ► c Eve.Phone:( ) Send results to:(Print full name,address and zip code or email address) RogiN GptkA_D Lt1 E CAMDFN %UK? i# r^Tn _vt to 9g Sg SAMPLE INFORMATION Sample collected by(name): RbB/NI 6( Al C Specific location or address where sample collected: Special instructions or comments: 8ti► E. CARDEN way '+.i • • • 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 0 Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coli-GWR(A/P) 0 Fecal-Surface.G'NI,springs lnumeration) Unsatisfactory routine lab number Filtered:Yes No - ❑Assessment Monitoring(Alp) — — —— ❑Other Unsatisfactory routine collect date: S / / 4.0 Sample Collected for Information Only Investigative_._ Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifonn Present and ►_ Satisfactory ❑Ecoli present ❑E.coli absent o .iform detected Replacement Sample Required: 0 Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. Ecoli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code: In M 9223B ❑SM 9222D Date and Time Received•s' ❑SM 9215l ■ Enterolert® a -23 (-15 Date and Time Analyzed: —' - Date Report-•• 2 ` Sample Number(DOH number plus fire digits) Lab Use Only: JH Form#331-319(revised niiie 2200028 MASON CO WA 07/28/2023 11:59 AM NOTCE GOULD *189181 Rec Fee: $204.50 Pages: 2 I IIIIIII IIIIII III IIII IIIIIII IIIIII IIII IIII IIIII IIIII IIIIIII III IIIII III1 IIII IIII Return To bowl 5 f i bin C)o,id gL E. Carelcio.R Lt�a►� d She 16n, RAJ ciVgL JUL 26 2023 J By JO Grantor(s): (1) Dp►k91os Goikkt , (2) RO (1Ov��d ? 6?O?3 Grantee(s): (1) PUBLIC RFCFjITO Legal Description (1) Tract- A 0f S tor+ Plat- MM 4i 34SS_G8 (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 1 2 n...3 I .- I 2_ - 9 0 © t 0 .S 31 "- 2-0 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) ( . O I ,- t 2 -9 O 0 l 0 Tax Parcel: (Connection 2) I 2_ 0 3 - l 2 - q D © 5 Q The system owner is responsible for keeping this system in compliance. The name of the water system is: 574( E. (nAme-eE1 ` tlt&y This system is designed to provide for two service connections. Pldnning 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 nqt) been granted one or more waivers from specific provisions of the regulations. Dated on this tQpc-day of , 20 2 3. Signature of Grantor(s): �� ( D�. (1) V91-4,614 p4�!G , (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 4,0V-4 day of , 20 /e0/5 ;- DO LCI. I S (oc."i.D 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. \\ � Not Public in and for State of Washington, jP'0�ssio.U</,�`' re ing at 5c`f Et eW ::oct.2s-2o2+0;;?' My commission expires: 4v a-7 NOTARY �'; N PUBLIC moo)' se!Uumbet,��oCj��\`� '/// ,WAS `N.` Page 2 of 2