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Home My WebLink AboutWEL2023-00020 - WEL Application, Design, Letter - 4/12/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, ,E,E 400 98584 SHELTON: 42 T 967XT ,�J/�1 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 NORTHWEST LOGGING COMPANY 2522 N PROCTOR ST #15 TACOMA, WA 98406 RE: WATER SYSTEM PERMIT: TWO-PARTY WWL2023-00020 26132 NE North Shore Rd 323332300020 The 2-party water system, North Shore Rd, 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 360-427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely, Pfr David Anderson Environmental Health Specialist Mason County Environmental Health 4 c"t `, MASON COUNTY Date Received ` b �' f I1. ' 1 COMMUNITY SERVICES Amo t Recew \r)" � '^h r, vo1w Building.Planning,Envuon mental Health,Community Health 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L ,D,U `D___ .^ b0 b Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE i1021 /C&JEs-r c-o61c /�4 CoM *1/ 26 3 . 122 . L(36to MAILING ADDRESS—STREET,CITY,ST TE,ZIP 2S2-2- N t Piz-0 -ioa_ s-r. - i S --ryl ti1/ DiA gPzio6 SITE ADDRESS-STREET,CITY,STATE,ZIP 2b13Z. tUt Warfh Sao iRd 74/UYA, (A)A 9.9588 PRIMARY PARCEL NUMBER(WELL SITE) 3233322Lgo1 yc �` SECONDARY PARCEL NUMBER(IF APPLI 2 ABLE) r 333� 23000Zo (�.910t � WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE LE\ear CIExisting A Well ❑Spring S,0V itCRcS 3.6 7 ACQES PROPOSED WATER SYSTEM NAME(REQUIRED) Now < 2-t. rc_t) PROJECT DESCRIPTION 4aO PA PrY CI"A le I•,.A-i— y s-1-E-, - DIRECTIONS TO SITE/CONDITIONS r 2 o A ►.0 tEG4 rj c.,/ •F tie5E15Alit- -reqklyA E.D + Id a✓ A 3 tpxlisiiTtl 14-o t t_y la) — 110Y a*► r/r be►ONATra l-hi c/ 'Fa- 7.Z r&i i-es t fT thitro I t" 1i6 s t-lott R b t *POLL-OLP FOIL .8 Ntt-fcs D(2►V-u ey J?L4 IsE did 1.-EF1" AULets F 1:00.4 t-RR-4E TSUACe- f- e Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) S ec Pt-Ftv1/4.-A-e-0, . C701 Coybo i 9 �6 p MCE0dC APR 12 2023 Y Submittals Checklist: (these additional items will be required for approval) tSatisfactory 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 RL4 3, ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) y] ❑ ❑ Are there roads within the 100 pot radius of the water source? If so, is road Or Countyor 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? ❑ ❑ Screened and vented? ,\ ❑ The well casing extends /6 above level ground /concrete slab? (circle one) (1 ❑ ❑ Is there evidence of a surface seal? "qt ; 117,q tj92 7 ❑ ❑ Does the seal appear adequate? _ I�3 07'7- Z ,31*. ❑ Is a variance necessary for well site approval? i 7 -y : 8PQIGS Comments IkVi MO cvo"I Cf) t.- Pass ❑ Fail Inspector Date (C c/ Z3 Review Step 2: Two-Party Review: YES NO NA g ❑ ❑ Water Well Report with adequate pump test file? // [,� If NO, date of Capacity Test ` 7/ ( ?3Driller �a(!t GPM tM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test gr ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN �7?7 20�3 71 g9917 :e' ❑ System appears adequate to serve 2 single-family residences based on information provided? yi Comments — V-0 ppi/Q1v It (f p 4 P9 bv¢ rniYi mvrn ►2' c, P , -- 1/71 to 73 - aU0 8'0 a fed i/ct�� ►ntYlll►ih" a r fi1odc c t,1 P�ot � i' fv t tl ifO yll yy 7 tgi) Approved ❑ Denied Reviewer Date 8( G/C 03 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 19ll, 2018 per ESSB 6091. Revised: 1 0/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 17e6SEt teHll1 °' i‘ " ' SRF.CTRA Laboratories - Kitsap Port Ordure,VIA E _ —_.J... -- - 98366 1 ...Where experience matters i COLIFORM BACTERIA ANALYSIS FORM Date Sample Golf/clod Time Sample (/ � County t r., Collected ll r `�Z/ - 6iti /,.�3 G : pb . 11 Qn Moral Day ',liar _ Type of Water System(check only one box) . 0 Group A ElGroup B &Other i (1 Group A end Group B Systems-Provide from Water Facilles Inventory(WFI): . IDS ( h � N. C n System Name: 2(Jj I 1 J c N' ` it t r3�e ..0 Contact Person: Day Phone:( ) Cell Phone:( ) • Emit Send remelts to.(Print he name,address and zip code email ._. AY( IAt� SAMPLE INFORMATION Sample collected by(name): `t j/y/ Specific location where sa le collected: Special instructions or comments: Type of Sample(select only one type of sample from types i through 5 below) 1.0 Routine Distribution Sample(MP) 2.0 Repeat Sample(AfP) Chlorinated:Yes No (from dishibubon system attar uns4 routine) Unsatisfactory routine lab number: Chlorine Residual:Total_Free_ 3.Ground Water Rule Source Sample ——— l5 l 1 ! Unsatisfactory routine collect date: __ I Chlo inated:Yes No ❑Triggered{A/P) Chlorine Residual:Total_Free_ ❑Assessment (AIP) 4.Surface or GWl Raw Source Water Sample(Enumeration) I S ! l ❑E.coil ❑Fecal Filtered Yak__no 5.pi Sample Collected for information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsattstactory Total Coliform Present and Pitlsfactory ❑E.006 present 0 Ecoli absent Bacterial Density Results:Total Caton mpn/100m1. E.coli moo/100ml. Fail Colifomn du 1100rrd. HPC /1 ml . Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample volume ❑Damaged Container 0 Lab Retuancs Number rl - OLto 2-78sz}b -ti) Receipt Temp C° Method Code: SM922313 or SM9222D Date Reported le DOH n Lab the Only: JUN ?2 '� '3 DOH LabSamola > O(05O 0( I DOH Fee O314191ib6»Wein.91w roe0 ti pbtam run ot o.os urool M cOi125.01Y!(WONT'mg 11 i; Ow and ober p.tiofors reoarbbe ay..eha. qmoo• t,09,02.3 - 00379 1 Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C ...Where experience matters Poulsbo,WA 98370 Phone: (360)77 EIC E I V E D www.spectra-la .com AUG -1 2023 615 W. Alder Street Spectra Labs - Kitsap, LLC (Poulsbo)received samples for Davis Drilling on Wednesday,June 21, 2023 at 1:40 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 228506-01 26141 NE N Shore Rd Well Head 06/21/2023 9:00 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.spectra-lab.com. This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 06/28/2023 Page 1 of 1 WATER WELL. REPnRT !Pic DEPARTMENT OF Notice of Intent No. WE52891 tt.V LL G Unique Ecology Well ID Tar No.BPQ 165 — Type of Work: State of Washington G Construction Site Well Name(if more than one well): C Decommission Original installation NOI No. Water Right PemtiiCertificatc No. Proposed Use: ?Domestic C Industrial ❑Municipal Property Owner Name NW Loaoino u Dew atering ❑Irrigation C Test Well l Other Well Street Address 26141 NE N Shore Rd —. Construction Type: Method: M New well ❑Alteration r.Driven E Jetted M Cable Tool City Tahuva County Mason ❑Deepening C Other _Dug ^_.Air- C Mud-Rotary Tax Parcel No, 32332290140 Dimensions: Diameter o.`boring 6 in..to 80 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 65 ft. Construction Details: wall i If yes,what was the variance for? _-•— Casing Liner Diameter From To Thickness Steel PVC Welded Thread - 13 1 G 6 in, *1 45 1,4 in. p 1 Q E. I C Location(see instructions on page 2): E3 WW?.1 or 7 EWM It 1 U 6 in. 68 70 1/4 in. a❑ 1 0 I C NW y-'L of the NW r,.,Section 33 Township 23N Range 3W 0 i ❑ in. in. ❑ 1 D ❑ 1 O a I ❑ in. in. ❑ 10 0 1 ❑ Iatitude(Example:47.12345)47,44451 Longitude(Example:-120.12345)-123.07920 Perforations: :l Yes l 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 surface Formation:Describe by color,character,sire of material and structure,end the kind and nature of the material in cacti layer penetrated,with et(cast one entry fur each change of Screens: A Yes ❑No A K-Packer ' Depth 42 ft. in:orrmatron. Use additional sheets if necessary. Manufacturer's Name Johnson ",IVIatcrial .i - • • Erato To Type stainless Model No. Diameter 5 in. Slot size 14 in.from 45 ft to 65 ft. Reddish brown conglomerate _0 38 Diameter in Slot size in from ft to ft. Light brown sand&gravel saturated 1 38 — 65 Clay bound sand&gravel 65 80 SandiFilter pack:❑Yes E No Size of pack material in. Materials placed from ft.to ft. Surface Seal: Al Y . 0 No To what depth? 18 ft. Cut drive shoe at 68'pull casing back to 45' - Material used in seal bentonrie Did any strata contain unusable water? 0 Yes ❑NoI — Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Type: H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surrice elevation above mean sea level ft Stick-up of top of well casing ft above ground surface Static water level 26.5 ft.below top of well casing Date — Artesian pressure_lbs.per square inch Date — Aresian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping tat performed? C No 0 Yes b by whom? — Yield gpm with fl.drawdown after_hrs. Yield gpm with_ft.drawdown after_hrs. Yield gpm with_ft.drawdown after_hrs. Recovery data(time"zero when pump is turned ofT-water level measured from well top to water level) Time Water Level Time a Water Level Time water Level - — '----— Date of pumping test Bailer test 1 gpm with 38_5 ft.drawdown after 1_hrs. i Air test—gpm with stem set at ft.for hrs. - Date — — Artesian flow—gpm _ ' Temperature of water "F \Vas a chemical analysis made? 0 Yea C No Start Date 6/7/23 Completed Date 7/112: WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance wiih all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. El Driller;.,Trainee C PE-Print Name Emily Davis Drilling Company Davis Drilling Signature CAN.)---- Address 340 NE Davis Farm Rd License No.3142 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI110OA Date July 2023 q I