HomeMy WebLinkAboutWEL2022-00047 - WEL Application, Design, Letter - 9/28/2022 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
J 4 •• BELFAIR:360-275-4467,EXT 400
3`'" / Public Health & Human Services ELMA:360-482-5269,EXT 400
a FAX:360-427-7787
JENNINGS ET AL BENJAMIN C & JESSICA ANN
FOSS
BRANDON WOLF & SAREANA WOLF
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2022-00047
301 E HOLLOWPOINT DR
321262394001
The 2-party water system, Ridge Top 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 360.427-9670 Ext.353 or email at
Icencula@masoncountywa.gov
Sincerely,
RV1O rtaol T{l\km P V
Environmental Health Specialist
Mason County Environmental Health
ilo .
;;., MASON Date Received COUNTY q — 'L 8 • a.Z
n. COMMUNITY SERVICES Amount Received Rece` d BY
Puil<hnq.PLumii.9.Emuron manta!Health,Community Health 50 .. ..... .........---L-_.........vit
4I 5 N.6"'Street.(Bldg 8)-Shelton.WA 98584 NE L 413 11 o b0 474
Shelton: 360-4227 9)67(1 x400 Belliair:360-275-1467 x400 Flma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLIC T PHONE
ntA J ' v.Z A S 36a--6 i - ISc-
t7ONG7X ADDRESS 11�4` 5 P
CITY r1 G1 r '
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SITE ADDRESS-STREET,CITY,S jTE, P /)
O , ,`�TE k � Vl'\T IV-d
PRIMARY PARCEL NUMBER(WELL SITE) I (�/r ^G ��VI
2(91d-C2a — og000 (�c of D /
SECONDARY PARCEL NUMBER(IF APPLICABLE) 11 V 32 IVtl r -/YO O
PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
WATER SOURCE SOURCE TYPE Well 0 Spring '�'q
�Ne�\ 0 ExistingP b 05 , 1-70 /S 0 f
PROPOSED WATER SY EM NAME(REQUIRED)
PROD CT DESCRIPTION 1
4)0 FA.w•i 4I^elk CGS (�S r donee_ ci-C. S c/<4tia'` P ) / s" Al c- - y_
I IN PIc...cc- -
DIRECTIONS TO SITE/CONDITIONS
Site Plan: (may also be attached)
(property boundaries, structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc—)
- � . I S Ep 0 b 7
2 8 2022
By !IV
Submittals Checklist: (these additional items will be required for approval)
ril Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
g Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
ix Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
7C1 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: 10.1; 2021
Page 1 cf 2
,
1 1
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ R❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ 0°../❑ Are there roads within the 100 foot radius of the water source? If so, is re-d private. .ourty or State.
What is distance to ROW? ' '' -V
la--"El ❑ Does the ground slope away from the water source site? (show slope on plot plan)
E ❑ ❑ Is the well cap satisfactory?
El ❑ ❑ Screened and vented?
y
ElThe well casing extends i b abov evel group /concrete slab? (circle one)
2***"..-0 ❑ Is there evidence of a surface seal? C,
L7 ❑ El Does Does the seal appear adequate? b 0 V 6-T
❑ E"❑ Is a variance necessary for well site approval?
Comments i,yq" ' S , - 05. Or 1 611
[Etl'ass n Fail Inspector Date l o`s i 1 lo_T'Y
Review Step 2: Two-Party Review:
YES�JO NA
[�❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
E ❑ Received Satisfactory Bacteriological Analysis? Date of test t 1 Q`ele
❑ Received Signed, Notarized, and Recorded Notice? AFN 2....A bb'7 -7
❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments ---
A roved ❑ Denied Reviewer s Date � 17'6 f?i 3
Pp ��
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. il-ater
System approval is a two-part process.
.4/I proposed connections to new wells are subject to water adequacy requirements at time of building permit per.t.1CC 6.68.
II'ater usage restrictions and additional fees may apply to all new wells drilled after January 19th, 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
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WATER WELL REPORT ,,,r.1 :t5„•,i DEPARTMENT OF Noticc of Intent No. WE45713
ECOLOGY Unique Ecology Well ID Tag No. BNV867
Type of Work: eigliWi State of Washington
O Construction Site Well Name(if more than one well):
O Decommission t=> Original installation NOI No. Water Right Pennit/Certifucafe No.
Proposed Use: El Domestic 0 Industrial 0 Municipal Property Owner Name Ben Jennings
0 Dewatering 0 Irrigation 0 Test Well ❑Other
Well Street Address Mason Lake Rd
Construction Type: Method:
t'9 New well ❑Alteration ❑Driven 0 Jetted 0 Cable Tool City Shelton County Mason
❑Deepening 0 Other ❑Dug O Air- ❑Mud-Rotary Tax Parcel No. 32126-20-04000
Dimensions: Diameter of boring 6 in.,to 179 ft.
Was a variance approved for this well? ❑Yes 0 No
Depth of completed well 179 ft.
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter Front To Thickness Steel PVC Welded Thread
IA I ❑ 6 in. 0 174 0.25 in. 0 I 0 0 I 0 Location(see instructions on page 2): g WWM or 0 EWM
❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑ SW /-'/of the NW V.;Section 26 Township 21N Range 3W
❑ I ❑ in. _ in. ❑ I ❑ ❑ I ❑
O I 0 in. _ in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.282828 N
Longitude(Example:-120.12345) -123.031800 W
Perforations: ❑Yes (No Type of perforator used
Driller's Log/Construction or Decommission Procedure
No.ofperforat perforations Size of perforations in.by in. Formation:Describe by color,character,size of material and structure,and the kind and
Perforated from ft.to IL below ground surface nature of the material in each layer penetrated,with at least one entry for each change of
Screens: l7 Yes 0 No E K-Packer b Depth 173 ft. information. Use additional sheets if necessary.
Manufacturer's Name Alloy Machine Works Material From To
Type Wire Wrapped Model No.
Diameter 5 Slot size.014 in from 174 ft.to 179 ft. Brown fine to medium sandy gravel,silt 0
Diameter Slot size in.from ft.to ft. bound,tight,dry 74
Brown fine to medium sandy gravel,gray silt 74
Sand/Filter pack:❑Yes O No Size of pack material in.
Materials placed from ft.to ft, binding,tight,dry 81
Black sharp gravel,gray clay binding,tight,dry 81 93
Surface Seal: E Yes ❑No To what depth? 19 ft. Brown medium to coarse sandy gravel,loose 93
Material used in seal Bentonite Chips
Did any strata contain unusable water? 0 Yes tEl No silty,wet 111
Type of water? Depth of strata Brown gravelly medium sand,active,wet 111 133
Method of sealing strata off Heaving coarse brown sand 133 139
Gray silt,stiff,dry 139 154
Pump: Manufacturer's Name Type: Gray silty brown fine sand,moist 154 157
H.P. Pump intake depth: ft, Designed flow rate: gpm
Gray clay,stiff,dry 157 172
Water Levels: Land-surface elevation above mean sea level 295 ft. Brown clay,stiff,dry 172 173
Stick-up of top of well casing 1 fl.above ground surface Coarse sandy gravel to cobles,water 173 179
Static water level 75 ft.below top of well casing Date 7/26/22
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? ❑No ❑Yes ' by whom?
Yield gpm with ft.drawdown after hrs.
Yield gpm with ft.dmwdown after_hrs.
Yield gpm with ft.dmwdown after_hrs.
Recovery data(time=zero when pump is turned off—water level measured from well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping lest
Bailer test gpm with_fL draw down after hrs.
Air test 75 gpm with stem set at 160 ft.for 1 hrs. Date 7/26/22
Artesian flow gpm
Temperature of water 51 °F Was a chemical analysis mode? ❑Yes E No Start Date 7/26/22 Completed Date 7/26/22
WELL 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—Print Name q hyfhier>' 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 7/26/22
ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
1786 SE Mile Hill Drive
Port Orchard,WA 98366
)t SPECTRA Laboratories-Kitsap www.spectra-lab.com
•-wk,,,•p•'it nee (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County •
Collected
8 I 16 I 22 Clam Mason
Mont On Year
3 '�5 ei PM
Type of Water System(cited(only one box)
❑Group A ❑Group B []Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: Ben Jennings
Contact Person:Arleta Eisele/Arcadia Drilling
Day Phone:360.426-3395 Cell Phone:
Email: arleta@arcadiadrliling.com Eve.Phone:
Send results to:(Print full name,address and zip code or eimai)
arletar�arcadladrilling.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Mason
Specific location where sample collected: Special Instructions or comments:
Well Head#BNV867
East Mason Lk Rd,Shelton
Type of Sample(check only one box)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes❑ No❑ ❑Distribution System
Chlorine Residual:Total Free_ Unsatisfactory routine lab number.
3.Source Ground Water Rule Sample ——-
S I I I Unsatisfactory routine collect date:
1 I
0 Triggered Chlorinated:Yes❑ No❑
Chlorine Residual:Total Free
❑Assessment
4. Ermnerabon Source Water Sample I S I I l
•
E coil [Yea-Surface,Gm,S rbr Filmed Yes❑ No
5.0 Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB U ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
0 E.coli present 0 E.cofi absent
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑— _— .
Bacterial Density Results:Total Coliform. 1100ml. E.coli_._-_._.._.I100ml. i
I
Fecal Coliform 1 0 I. IPC /1 ml.
Lab ID Number lY..
Method Code: Date and Time Incubated:
SM 9223 B AUG 17 2022
Date Analyzed: AUG 1 U i011 Date Repated j
DOH tab-Samoa :e PI
225 . _ __-_
oon FmnwtarsW,a au*.If ra meths peicatel+en dmmneramu cmeco.us.o,n 0(tmv ours).
Nu and dnr aricere,re ref a cm.t a vn.m+,..soea xvye.er.
2196677 MASON CO WA
03.48 PM
Return To JENNINGS23*186489 RecNOTCE Fee. 204 50 Pages. 2
t ��, n ifII4U tillifllI 1111131101 �P� NCI 1111411111 llllll
95
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Grantor ,�nC
s}: (1) � .11'1 �
t t� � hnr �� �O 3eSSt CO, nln4S
Grantee s : (1) PUBLIC �Q V
Legal Description (1) bre � --Q-� �nekcX' 1b� ��.
(A viated form:/Ii.e. lot, block, plat or section, township, range)
l
Assessor's Tax Parcel: (1) 3 .(.0 - 2 a
-` ` 44 0 0 1
NOTICE TO FUTURE RO • Y WNERS OF PRIVATE TWO-PARTY WATER SYSTEM
l (We)the undersig ran , certify that the water source located on the above-described
real estate under gal De ription (1) and Assessors Tax Parcel (1) situated in Mason
County, State ingt , has been designated to serve a source of water to the following
parcels situa a ounty, State of Washington; herein described:
Tax Parc i� (C ecti 1) Z 1 2 C2 - 2 3 -4 IA o 0 .
Tax P r el: nection 2) 3_1_2, Co - 2 4_ P a-2,
The owner is responsible for keeping this system in compliance.
the water system is:ZACi-e_ 1)Y `-fir
his sy m is designed to provide for two service connections. Planning and design approvals
obtained from the department prior to expanding beyond this number of services.
ditionally, a water right, obtained from the Department of Ecology, is required if the water
ern exceeds exemption standards.
This system (has/ has not) been granted one or more waivers from specific provisions of the
regulations.
Dated on this day of . 20 73.
Signa fir oT Gran r(s : r
(1) (2 ' J�1 <� 41nir-17s
Page 1 of 2
State of Washington
County of Mason
I, the undersigned, a Notary Public in and for the above na ty and State, do hereby
certify that on this ZN / day of 1/a7 , 20 Z,A •+ja;..,� C. Ie,,t,,170
OsJ TRtf 'cq A , �4„",;, t personally ap•.- ed :fore me, who is known to be
signer of the above instrument, and acknowledged that • -- -) (they) signed it.
GIVEN under my hand and official seal the day an . •ove written.
Notary Public otaaty-Public in and for the Sta of Washington,
resi
State of Washington i g at ? Or c
MARK LAMBERT mmission expires: -a,caory ( ZOZ-6
COMM.EXP.JAN.08,2028
COMM.NO.148355 '
0
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2196677 Page 2 of 2 05/02/2023 03:48:36 PM Mason County, WA