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HomeMy WebLinkAboutWEL2023-00036 - WEL Application, Design, Letter - 7/6/2023 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 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 id nderson Mason County Environmental Health ry 7 MASON COUNTY 7 date Received COMMUNITY SERVICES moJ ld.5 Recei Y cca„, BuiIJing,Planning Environmental Health,Community Health 4 15 N.6'a Street,(Bldg 8)-Shelton,WA 98584 WEL `"),() Q Co Shelton: 360-427-9670 x400 E3elfair:360-2754467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE lVoi /1�as 4 Govk! 253- 30t-751S MAILING ADDRESS-STREET,CITY,STATE,ZIP �+l E . CamAe.yn V\tay SheI+on, vt1\ 9853LJ SITE ADDRESS-STREET,CITY,STATE,ZIP �}� 4( E, eian le n wo y J1�2 I '}on, kVA ?SBi-1 PRIMARY PARCEL NUMBER(WELL SITE) i2o3t- (2-9ootO SECONDARY PARCEL NUMBER(IF APPLICABLE) 12D3I - 12 - gb)50 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑ New lE.Existing K Well ❑ Spring j 0.cire, I ..z(o u 4 S PROPOSED WATER SYSTEM NAME(REQUIRED) Corn* Lra�,- Tufo - Fc'y PROJECT DESCRIPTION Sha�rz, ultzil be v.)Or two con-Figu,o prope k-,1e. DIRECTIONS TO SITE/CONDITIONS Ca:5c ACtr•44-ir1P, klaru& b r AT,'. RA- br rr) South ktanclt A Turn }tarn of lAarsh'ez. isiat„t el cotkth for A 2 yeti leS t L,e_f4- an easi— CAmkleln Wllrry. (,all ctf key pael (DC jazz c&te . +=cilou; £ ('cvytde,. Weky - Turn lef co SSE( )1--`1kie..,vcy' Site Plan: (may also be attached) pbWn Weti, 6b1 �R19�,t (property boundaries,structures.well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc..,) Se, A41oothheo JUL 1 2 2023 al—01 M 11 JUL 0 6 2023 Submittals Checklist: (these additional items will be required for approval) Er Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) El Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) g Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) g 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: I0/13/202I Page 1 of 2 Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ V_ ❑ 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 ra iys of the water source? If so, is roe', privet- County or State. What is distance to ROW? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) r- ❑ ❑ Is the well cap satisfactory? '4 ❑ ❑ Screened and vented? it. ❑ The well casing extends 2 above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? r ❑ ❑ Does the seal appear adequate? ' ‘{t'L ❑ Is a variance necessary for well site approval? Comments (-0 - (� Y 3 3 I _ tom- 3''5-2YX ( Pass ❑ Fail Inspector Date .(4t,, .7 _ 13 �--3 VIIMINOSIIMMISMY Review Step 2: Two-Party Review: YESX NO NA ❑ ❑ Water Well Report with adequate pump test on file? �,Q ,.�,/ / If NO, date of Capacity Test 7/ 7/?O7I Driller Y dies �! /OTC(I(N GPM ? 0 � ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6�6( Z923) /❑ ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z7-0CJ1975 Ai ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments y.Approved ❑ Denied Reviewer __OV---'- Date 7/3//Zri—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 SITE PLI\ _Asr cAJADEt4 wttyr • W w A I ob31-0,- ./ S f — N M SEPTtc?Re paseo .P10,3 F�+SEMENT loos WELL PRoPERT)/ X -- f-- PRoPEeTY £Assr N c GASE.r1sNr Z . 121)3(-12-9acro ;4 SEprtc. APVRavED t 32' WATER WELL REPORT r J-AMIDLPARIMINI UI NoticeoflntentNo WE43401 ECOLOGY Unique Ecology Well II)1"ag No BMS072 Type of Work: State of Washington 1 Construction Site Well Name(if more than one%sell) ❑ Decommission r= Original installation NOI No. Water Right Permit/Certificate No Proposed Use: La'Domestic fl Industrial 0 Municipal Property Ossner Name Doug 8.Robin Gould Q Dcwatcring fJ Irrigation ❑Test Well ❑Other Well Street Address 841 E Camden Way Construction 1)pc: Method: El Ness%sill U Alteration ❑Uriscn 0 Jetted 0('able Tool City Shelton Counts Mason U Deepening 0 Other 0 Dug ©Air- 0 Mud-Rotary Tax Parcel No 12031-12-90010 Dimensions: Diameter of boring 6 in.,to 178 ft Depth ofcuuipleted well 178 ft Was a variance approved for this%sell? ]Yes ❑' No Construction Details: Wall It'yes,sshat sst.s the variance for'! Casing Liner Diameter from To Thickness Steel PVC Welded Thread O I 0 6 in 0 174 0.25 in 13 I 0 M I 0 Location(see instructions on page 2) D3 WWM or 0 EWM ❑ I 0 in _ _ in. ❑ I ❑ ❑ I ❑ NW Y.-r%of the NE 'V.:Section 30 Tossnship 20N Range 1 W ❑ 1 ❑ in _ in ❑ 1 ❑ ❑ I ❑ Latitude(Example 47.12345 47.184599 ❑ I ❑ in _ in ❑ 1 O ❑ I ❑ P ) Longitude(Example-120 12345) 122.852580 Perforations: n Yes • No Type of perforator used No of perforations_ Site 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,rindand the kind a nature of the nateriat in each layer penetrated,with at least ire entry fix each change of Screens: G1 Yes U No fin K-Packer =' Depth 172 fl information Use additional sheets if necessary Manufacturer's Name Alloy Machine Works Material From "to Type Wire wrapped Model No Diameter 5 Slot sire.016 in from 173 ft to 178 fl Brown fine sandy gravel silt bound,tight,dry 0 18 Diameter Slot site in from Ili to ft Brown some gravelly fine sand,tight.dry 18 38 Sand/Filter pack U Yes No Sire of pack material in Brown gravelly fine sand silt,bound,tight,dry 38 69 Materials placed from ft.to ti Brown fine to medium sandy gravel,sharp, 69 tight,city 90 Surface Seal: G1 Yes n No To what depth'' 19 ft Loose medium sandy gravel,wet 90 102 Material used inn seal Bentonite Chips Did any strata contain unusable water' fl Yes O No Brown clay,stiff,dry 102 112 hype of water'' _ _ lepth of strata Brown fine silty sand,dry 112 143 Method of waling strata off Brown fine sandy sharp gravel,tight,dry 143 149 , Brown fine sand,wet.tight 149 156 Pump: Manufacturer's Name Type _ Brown gravelly medium sand.heaving,water 156 II P. Punnp intake depth: fl Designed floss rate ppm bearing 174 Rater I.evels: Land-surface elevation above mean sea tescl 143 fl Brown course sandy gravel,heaving,water 174 Stick-up of top of well casing 1_5 fl above ground surface bearing178 Static water level 119 ft below top of well casing Date 7/7/21 Artesian pressure lbs per square inch Date Artesian water is controlled by (cap,sake,etc) Well Tests: Was a pumping test performed' E.)No Cl Yes a=_ • by whom' Yield ppm with ft drawdown after pus. Yield giro with ft drawdnw n after los. Yield gpm with ft drawdown after hrs !teem cry data(lime-zero when pinup is fumed off- water level measured from well top to water lesel) Time Water Level Time Water I esel Time Water I.esel - -- -Date of pumping test Bailer test ppm with_ft dais doss n after_Ins Air test 30 gpm with stem set at 160 ft for 2 his - Date 7/7/21 Artesian flow ppm Temperature of water 51 °F Was a chemical analysis made"' U Yes lei No Stan Date 7/6/21 Completed Date 7/7/21 WELL('O\SIRU•C ION CERTIFICATION: I constructed and/or accept responsibility for construction of this%sell,and its compliance ssith all Washington well construction standards Materials used and the information reported above are true to my best knossledge and belief ❑Driller Li'trainee':J PE P 'a • Roger 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 No Contractor's Sponsor's Signature Registration No ARCADDI098K1 Date EC Y 050-1-20(Rev 09/18) lfou need this document in an ahernate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 7!I for Washington Relay Service. Persons with a speech dmsahrluy can call 877-833-6341. Thurston County Environmental Health � � 2000 Lakeridge Dr.SW •Olympia,WA � 98502 rHCO ®rY 360 867-2631 COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample Collected County 6 1 z3 /,y/�Mond Day Year :20 0 Ph1 • ` � Type of Water System(check only one box) ❑Group A ❑ Private Household ❑Group B W Other. ttilp (Z X Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: -- Contact Person; Rog' 0 ` _, Day Phone:(25• ) `, Cell Phone:(ZS E-mail:robihde5 i.r1S Send results to:(Print full name,address and , ' Evs ( ) zip code or email address) • , SAMPLE INFORMATION Sample collected by(name): 'w8/lei Ge LD. Specific location or address where sample collected: gH i E CA MD E I+' , -, Ll.i Special instructions or comments: • • Type of Sample(must check only one box of#1 through#4 listed below) 1.pil Routine Distribution Sample 2.Repeat Sample(after unsat routine) Chlorinated:Yes No Chlorine Residual:TotalID Distribution System Free Chlorinated:Yes 3.Raw Water Source Sample No Chlorine Residual:Total Free ❑E.coli-G WR(A/P) ❑Fecal-Surface.Gwl springs(numeration) Unsatisfactory routine lab number; Filtered:Yes No ❑Assessment Monitoring(A/P) — — — ❑Other Unsatisfactory routine collect date: S / / 1•❑Sample Collected for Information Only Investigative Construction/Repairs LAB USE ONLY DRINKING WATER Other ]Unsatisfactory Total Coliform Present and RESULTS LAB USE ONLY ❑Ecoli present Satisfactory 0 E.coli absent o Piifonn detected placement Sample Required; Sample too old(>30 hours) ❑TNTC aerial Density Results:Total Coliform �/100m1. E.coli m1. Decal Coliform �_/100 ______/100m1 Enterococci lod Code: ► M 92236 ❑SM 9222D e/100 ml. Date and Time Received.i`'' ❑SM 9215B ■Enteroler(® Ind Time Analyzed; — elMillin Date (p 23 fil S Number(DOH number plus five digits) Report•. . - 2'� 8 0 -3 t Lab Use Only: 1#331-319(revised 01/16) ;\l 2200028 MASON CO WA 07/26/2023 11:59 AM NOTCE GOULD #189161 Rec Fee $204.50 Pages: 2 IliiiDIIIIIIIIIIllllll I IIIDIIIIIIII IIIIII IIIIIIIIIHI IIIII Return To -Ou3 5 tob�n Could. 9K353q JUL 26 2023 b By J Grantor(s): (1) Dp�tk,laS Gle At� t (2) tob • • o` 2 6ZQ Grantee(s): (1) PUBLIC RFC��V D ?`� Legal Description (1) I roc± A 0( Sknr-t Plat he 4 39sica, F (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) l 2 n .3 t - 1 Z - 9 O O I, O 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) ( . 0 I - l 2 - q © l O Tax Parcel: (Connection 2) 1 2 D 3 ( - l 2 - 9 0 0 5 D The system owner is responsible for keeping this system in compliance. The name of the water system is: 5114( E (2Avnl;en VUri{\' 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 77A-day of , 20,2?,. Signature of Grantor(s): (1) /� / , (2) . �v Page 1 of 2 A 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 0-4 day of /--y , 20 /e0/5/ D 0C2 4,[. s 69 0,i z-C".cj 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, \ P •*** .,</9'%,� re ing at 5lf2clJZ�/✓ • `.(( 62 4o'•. My commission expires: (o'v?w -a-1• NA PUBLIC moo,; •s•'•umbet 1�" A0S ////0Fl iWASN`?\' Page 2 of 2