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HomeMy WebLinkAboutWEL2023-00040 - WEL Application, Design, Letter - 7/17/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHETREE ,SHE TON, , EXT 400 584 tr00 BELFAIR: 360-275-4467, EXT 400 Public Health & Human Services ELMA:360-482-5269, EXT400 FAX: 360-427-7787 EWING ET AL DONALD A 262 NW 43rd St SEATTLE, WA 98107 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00040 460 E Libby Rd 320245000014 The 2-party water system, 460 Water, 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 OM ``^.. MASON COUNTY Date Re`e d l(R- (4P--00-: "F '$) COMMUNITY SERVICES '.mount Received Rece vea I3y. pv,al Building,Planning Environmental Health,Community Heahh 415 N.6°i Street,(Bldg 8)-Shelton,WA 98584 W E L �0a2) - 00 0'V Shelton: 360427-9670 x400 Belfair:360-2754467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE MAILING ADDRESS-STREET,CITY,STATE,ZIP SITE ADDRESS-SSTTRR-EEEVT,,CITY,STATE,ZIP ` PRIMARY PARCEL NUMBEr0ELLS—TE) -//(gg Y ISN'T) / d c?0 SECONDARY PARCEL NUMBER Op APPLICABLE) 8-1 -IA 1 7 2023 Li- WATER SOURCE � CI _ New F,xisting ,,Well ❑ Spring I . OaY 5 /L_Zc PROPOSED WATER SYSTEM NAME(REUt IRED) PROJECT DESCRIPTION -ram PA—' ze7 a 5��. _.g-r //)r. )0 --e-Ix/4 c-Agivi + V ,7 X cV____ A 774-0=77- >. DIRECTIONS TO SITE/CONDITIONS -r Tim tZD . n44 7.I7 z G— Z / 1342%.1. i (. -� Gc. a) -1t -÷ -e x,c-717�Cje— 7.C�( --- jl._t__ Site Plan: (may also be attached) iproperty boundaries. structures.well site w/100'radius,driveways,roads, septic/sewer components and lines, easements,etc...) Submittals Checklist: (these additional items will be required for approval) tgl 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) his 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 ❑ 14i ❑ Evidence of existing sources of contamination within 100 foot radius of water source? 111���,,,,,, (drainfields, tanks, buildings; indicate distance on plot plan) ❑ lyl ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State. What is distance to ROW? ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? N( ❑ ❑ Screened and vented? /' No ❑ The well casing extends /e above level ground/concrete slab? (circle one) r ❑ ❑ Is there evidence of a surface seal? 141. ' 9 f .L07?S30 j Irg ❑ ❑ Does the seal appear adequate? tor) ; -ill. ?f6 F70 ❑ y ❑ Is a variance necessary for well site approval? 1 T I9` A F( gSy Comments Pass ❑ Fail Inspector /0-\._ Date 77C/202,3 Review Step 2: Two-Party Review: YES NO NA 14 ❑ ❑ Water Well Report with adequate pump test on file? 3/3/?003 5 If NO, date of Capacity Test Driller GPM 30 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6/2 7/2023 ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2(9' 616 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments /q Pp RoV - -- - MAs Uz'UG032 A-Approved ❑ Denied Reviewer Date riewi e ✓A rAc N ✓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 lime of building permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19`h, 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 Thurston County Environmental Health II 2000 Lakeridge Dr.SW t Olympia,WA 98502 360 867-2631 TFIURSTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected aM • aq f la:: 7J 1L(A5 V Ni 0 PM Month Day Year Type of Water System(check only one box) Private Household ❑Group A ❑Group B 0 Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: 174>a/1.1.4 2C INI l / Day Phone:( a 4.qe, ell Phone: ) E-mail: ��j, 620, ve.Phone:( Send results to:(Print full name,address and zip code or email address) __- �_64) 31- _-5 �.._......___ /A '11 , l — SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: .0f kt 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_ ❑E.coil-GWR(A/P) ❑Fecal-Surface,GWI,springs(namerahon) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: DOther S - 4.0 Sample Collected for Information Only Investigative Construction/Repairs other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present andt71. atisfactory ❑E.coli present ❑E.coli absent o oliform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli 1100m1. p Fecal Coliform /100m1 Enterococci /100 ml. Method Code: SM 9223E :ISM 9222D Date and Time Received: ❑SM 9215B ❑Enterolert® C•ZI 23 Date and Time Analyzed: 'Z , Date Reported PA•3,. Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 5 6 I Please print,sign and return to the Department of Ecology we- 0 Water Well Report C1teAt W165437 Original-Ecology,I'd copy-owner,2°d copy-drukr NottceofIntentNO. E'C�b�I O G Y Construction/Decommission Unique Ecology Well ID Tag No. AFG859 O 0 Construction Water Right Permit No.EXEMPT WELL W ❑ Decommission ORIGINAL INSTALLATION Notice Property Owner Name DONALD EWING et /3o7'i/ of Intent Number( Well Street Address 460 E.LIBBY ROAD 4) PROPOSED USE: ©Domestic ❑ nndustn l 0 Municipal City SHELTON County MASON ❑DeWmnr ❑ltng+uon ❑Test Well ❑Other Location sw1/4-1/4 NE 1/4 Sec 24 Twn 20N R3W Er mode to TYPE OP WORK: Owner's numb r of well(if more than one) W WM e/ sir ;_ ©New well ❑Ftwondmoned Method ❑Dug 0 Bored ❑ Driven Lat/Long(s,El Deepened (l Cable ❑Rotary ❑Jetted t,r Lat Deg Let Min/See C DIMENSIONS:Diameter of well 6 Inches,drilled QS ft still REQUIRED) Long Deg Long Ivitn/Seo O Depth of completed well 93 ft C CONSTRUCTION DETAILS Tax Parcel No, 32024-50-00014 O Casing El Welded 6 " Dien from +2 ft to 82 ft +' Installed: —Later Installed " Du;m from ft to ft CONSTRUCItoN OR DECOMMISSION PROCEDURE Ri =Threaded " Dian from fL to ft EPerforations: ❑Yes ©No Formation Describe by color,character,we of material and reductlme,and the kind and Typeof itamor uuod aatum of the material in each stratum penetrated,with at least one entry for each change of 0 pm-rondo( information indicate all water encountered. (USE ADDTTJONAL SHEETS 15 NECESSARY) G SIZE of pods m by tn.and no.of perfs_from_ft to ft MATERIAL FROM TO — re- Se n: RI Yes ❑No El K-Pac Loc:tnan 80' DARK BROWN TOPSOIL 0 1 CD Manufacturer's Name JOHNSON SANDY AND GRAVEL 1 7 Type SLOTTED Model No SILTY BROWN CLAY,SAND,GRAVEL 7 38 Dram l Slot size.018 from 85 ft to 91 R O Diem Slot Slot size from A.to a. GRAY COMPACT CLAY,SAND, 38 "" Gravel/Fitter packed:❑Yes ©No 0 Size of gravel/sand GRAVEL 57 = Maur i s placed fran ft to ft GRAY HARDPAN 57 82 CU Surface Sol::El Yes ❑No To what depth?25' ft. SAND,GRAVEL,WATER 82 93 I Mmuwlusedmxel BENTONTTE SILT BOUND SAND,GRAVEL,WATER 93 95 tU Did any manse canton unusable wad? ❑Yes la No O Type of weta7 Dscxh of sums Q) Method of sealing strata o — 'C PUMP; Manufacturer's Name ..Type ----__ I-LP C WATER LEWIS: Landsurfirce elevation above meat sea level ft iSmuo level 33 ft below top of well Date 3/3/03 i. Artesian pressure- Ibs per squat inch Date CU Artesian water is controlled by , t_t__ive ate l ,, WELL TESTS:Drawdown w amount water level is lowered below static level OWee a poop test made?0 Yes l 1 No If yw,by whom? 2 Yield J tUmm.with ft drawdown after lhrs Yield .gal./min.with ft drawdown after Fey V) Yield gaUmwith m. ft dhewdown after lire O Recovery data(thane taken as zero when pump turned 4I,Q(water level mmrioul from we lop to l) .raoreter `J-i i v_� Time Water Level Tune Wake Level Tnmo Wetor Level R.L..1�, ,--� i — ---- 0 0 -- _. --- - .- A RR 1 17,003 0 Date of teat !L Baler tea 30 gel/tam with 20 , ft drawdown after hat.A W 11 ll i tl��I O Ii State utest gal withstem set at ft for_ he O Artesiaatlow R.p.in Doe T Depart mew 01 Ecol4ay, 4-0 Tanpctuuue of water Was a chemical analysis made? ❑Yes ®No C Stan Data 2/24/03 . Completed Date 3/3/03 IFl —_ EWELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all L. Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. CU Drdler/Fmgineeranunee Nome(Pant) D LSON Dntmg Company ARCADIA DRILLING INC. CDDnllce/EngsneafTcauue Signature 170 SE WALKER PARj{IWAD n Duller or trainee License No 1886 City,State,Zap SHELTON WA 98584 ,i 0 If TRAINEE, 1 Conlroctors Urlllei's Creamed No. Regtara Ian No ARCADDIQ98K1 Data 3/4/03 Drf➢er a Styeature Ecology is an Equal Opportunity Employer ECY 050.1.20(Rev 2/03) 2199616 MASON CO WA 07/17/2023 01:50 PM NOTCE DON EWING #188819 Rec Fee: $204.50 Pages- 2 JII II IIIIi III III IIIIIII III II III II I II II II VIIIII III IIIII III IIV III Return To ix- a wlilL? z-( 2- u_) 4?, jtr C / c.e_7A , ' (n-f Grantor(s): (1)' L 9-/1\C-V <4_ , icL7 , (2) Grantee(s): (1) PUBLIC Legal Description (1) _ __ 5 1-1- --r—Z cL, P _ (Abbreviated form: i.e. lot, block, plat or section, township, ran e) Assessor's Tax Parcel: (1) 2j 2 O Z- 1 - S C> - n O c / 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) Z- 2- �`t-- -S C3 - r-› >c > ( Tax Parcel: (Connection 2) 7 Z. 7-`€_ S 6 - C>c n 1''f The system owner is responsible for keeping this system in compliance. The name of the water system is: �� te-7 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 i - day of L`il.L , 20 2-5. Signatur • Grantor(s): (1) g <� -rC , (2) S 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 I i day of J ii( l i , 20 23 o-r, d j . EWi ns 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. \\\‘‘ N ����'�n,, Notary Public in and for the State of Washington, P. . �;ssioq� Q,�% residing at y �3a�'c, 5\i‘e1 � oc"g.oa-? + My commission expires: PO / v Ilt2(o s -A PUBLIC Acol i — Page 2 of 2 \I I u< \ a \�\ i[ a a 0 . • i i8t I I Si IIsasgs ss I J R S Rq !1 Le e R W R g$g li i "s�, I -12 I ' 55 °� I R $ � 1 I 1: � I ° \ �� \ , "N I `\ \\` w(/ i 1,-,,-,04,„, _ _. xMjO y` g O mINI a 6,„le° $ I - 1 ° lig If] I 9 e s - T p ° I 6gt el I El , 8 1 it 0-�LZ '-q 9 I R c o al L1 m o ° o I I , 11 ,, 6...? § .. II c- T NH a 3 II � I a � f 4 i. I Li • i K. L s I 14 67.s- �m i R° v 0 NA X ,y -aT (n48 om NS �igo a g g o 33 0 s g f.-o, m • A dt .. Hammersley Inlet Residence a 4,, 5 1 W O o Cr D a n g m Shelton,WA 98584 -4 n H ns _ m Vf P. 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