HomeMy WebLinkAboutWEL2023-00052 - WEL Application, Design, Letter - 10/2/2023 elint MASON COUNTY 415N6T"STREET,SHELTON,WA 99564
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
STORMANS GREGORY D & CRISTINA
7637 COUNTRYWOOD DR SE
OLYMPIA, WA 98501
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00052
10551 E State Route 106
322255100029
The 2-party water system, Patricia Beach Waterworks (322255100029/322255100030), 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,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
ri� MASON COUNTY Date Received 1
COMMUNITY SERVICES �n Rn=
el
,, Building Plmnq.Envhmment.Health communeHeam �
415 N 6°Street,(Bldg 8)-Shelton,WA 9S5n4 WEL �, _.0°OS
Shelton 3611-427-9690 000 Bellew 360-2754467 x400 Ehna'.360482-5269 54011
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APP
LICANT PHONE
rCZGor -7 I:46 rnrt- 'S c., r-Y r,,.. _ ter us - --.1 . - .- ) i7
MAILING ADDRESS-STREET,CITY,STATE,2f
SITE ADDRESS-STREET CITY. TATE ZtP / /
P l_ �/r 1 v pl^ , ( }/1 ) / ) l( t 7 _'i �0.PRIMARY PARCEL NUMBER(WELL SITE)
Z. 2_2-7-6 — 5 ( — [) 71,7 C.
SECONDARY PARCEL NUMBER(IF APPLICABLE)
?ZZZS- 5/ — cool°
WATER SOURCE SOURCE TYPE PARCEL I LOT SQE PARCEL 2 LOT SIZE
0 New Existing la Well 0 Spring bb vb. ,�
PROPOSED WATER SYSTEM NAME(REQUIRED)
d 7 _
PROJECT DESCRIPTION
DIRECTIONS TO SITE/CONDITIONS ' (
Site Plan: (may also be attached)
(property boundaries.structures,/ well site wil 00'radius,driveways,roads,septic/sewer components and lines,easements,etc.-)
.tr C ,M-e(" �. i 1
OCT 0 7 ailed
RECEIVED
1
—
Submittals Checklist: (these additional items will be required for approval)
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)
re 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 Sitg Igsp ction: _517S {/ilk 71
YES NO NA ` I}ol/Ce 65 -DT >AV
X ❑ 0 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 fri(adius of the water source? If so, is road private, County or ate. I
What is distance to ROW? (5
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ 0 Is the well cap satisfactory?
❑ ❑ Screened and vented? /�nn i1
❑ The well casing extends O above level ground/concrete slab? (circle one)
1g ❑ ❑ Is there evidence of a surface seal? UN-: 47 3i 51167
to) ; -123.00 Sil0S'
❑ ❑ Does the seal appear k V
adequate? 74 ;rteaz1L
0 06 ❑ Is a variance necessary for well site approval?
Comments
( Pass ❑ Fail Inspector Date 10/ I1 /Gi Z)
Review Step 2: Two-Party Review:
YES NO NA
/ c{ ❑ 0 Water Well Report with adequate pump test on file? �n�n t.n }
,t�s If NO, date of Capacity Test l2(JQr2003 Drillerb" `el)�114 II GPM ie
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 629(70z)
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 22029I I
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments /p�/
/ /Approved ❑ Denied Reviewer L/// Date 2y/70t i
Findings in this review reflect observed conditions as they existed on the day of the sire inspection. Aro claim is made, express
or implied of theluture success or failure of this system. Well site approval does not constitute rater system approval. Water
Svvtem approval is a two-part process.
All proposed connections In new wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additionalfces may apply to all new wells drilled(Vier Jan uwy 19t, 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
. ___. __-
WATER WELL REPORT NoticeCURRENT
IntentNo. W I IS 299
1 IT i'Sb'i Ongmal&1st copy-Ecology,2nd copy-owner,3rd copy-driller
Construction/Decommissionr"="in nrrlU Unique Ecology Well fD Tag No A)4Q ��
y1 Q(Construction Water Right Permit No.
C 0 Decommission ORIGINAL CONSTRU(T/ON Nonce �(� I� p
a. IUgg/2r�4Jlmen:Number U) 1,25,211 property Owner Name /the Al n1ETN /t . Sloe hlia'.45
cePROPOSED USE: IIKDomesoc Dmdusmal 0 Municipal Well Strew Address /O5SOI E. ay JC4
❑Dewatn ❑Imgabon 0 Test Well Dotter
y City 1)fNsO(1) County: m asoN
TYPE OF WORK: owners number of well Of more than one) I oration-IL1/d-I/d Nf4 Sec/ -lvn R�
EWM curie
igNew Well 0Recondmoned Method 0 Dug ❑timed ❑Dri.ve_n
Np0Deepened ableCaRtme 0 Rotary 0 Jetted LatMng: lot Deg Hat Min/Sec
as DIMENSIONS: Diameter of well 6 inches,Q dnled_ '9 ft (RV still
ODepth of completed well pi0 ft REQUIRED) �L✓nLoo pe�—, Long hLdgee
C CONSTRUCTION DETAILS Tax Parcel No. .22 5 ' S ! IT00021
O Casing ,®Welded a Di am from+I%I ft to 7241 CONSTRUCTION OR DECOMMISSION PROCEDURE
N Install d: ft m R Formation'Describe
by color,character.size of material and ucre,and the
❑Liner installed Dam ham-- kind and nature of the material in each stratum pcnetated,with at least one
E ❑Threaded Dram hoed ft toR entry for each change of information Indicate all water encountered
O Perforations: DYes gNo (USE ADDITIONAL SHEETS IFNECESSARY)
IF
O Type ofpedorator d - -. - - - 1 - MATERIAL _ FROM TO - -
SIZE ofperts_m by in and no of pests fromft to ftSAwd+61%Ru et' +4S O• L.
L Sacere:12ya 0 K-Pac Locationa+ Manufacturers Nameme Psi m/4..3. . AI IA/ Nl / I OOSC IiafaWN D
O Type in 4-15 5 Model No Co.vT l u.ead
D5 Slot Size a30 Roma SO R m fl S 11. 0e/rte ewe4 SR..d tGRw aat.
c am .14
roam S Slot Size 116 fro h5 R to 1 i ft 13. AtA CLAY Huard be,Raal 8 2-5
CutO
Gravel/Filter packed: Dyes g No 0 Size of gravel/sand
ims
eg Materials placed from ft to ft G/A m,i a L T: ct 1 GRw-T Kell
O Surface Seal: attics 0 No To what depth? I S I ft JJ/PI to UM,Yifa�1 /tam.) 25 -i S
LMaterials used mRai la ern1 a e.r.""Tra...aTF f A.bat h
•a Did any sn is contain unusable watert Dyes ZNo HL0 Su.J'} G RAVcL-ICoHRteS
IN Type of water Depth of state Coo SC 5,..1— I$`
Method of sealing strata off
no
PUMP: Manufacturer's Name
to m e bARt l3Lf. 3 5 60
R Type. H P p, / SA.416Ro(t L+Co,5nL-eS
WATER LEVELS: Land-surface elevauov above m am ealevyy ft
roM/ Tre
I" Siam
Sialevel 11 ftbemw ton ofwell Date Dec 2003 IIeR-r 1-4n4 APiweed A0 GS'
Z •
Anesan pressure lbs per square Inch Date + 0
Artesian water is cannoned by 1L//ZO Sot It6RAoe1.telOt SVi
10 (cap,valve,cm) LAOS& C Loi L.40404/
O WELL TESTS: Drawdown is amount water level is lowered below static level twc /// �-Y$ SSJ
-0Was a pump test made"❑yes O No If yes,by whom" - (1'm
Yield_gal/rum-with - - --R dnwtlown after - - - his - L — 1
o Yield _gaIhmn with ft drawdowm after hra ,RPucc+LlC.oy f 14ti€F -
Yield.-_callow with ft dnwdown after Ems -
-r;Gin- ANR M a0N *0 7
Recovery tiara(twit taken as zero when pump turned warer level mew'medf m rr22��fr��?dw p�y b�rraa
W wee toped wafer level) LS[�l-IL' ( V i a " Or
._ Time Water Level Time Water Level Time Water Level
- --- IAN 0 7 2004
e
01 Date of tat DGFAIIFIALDI Cl ECOI.00°
, Bader test 3O palmmn with I It dawdovm after_t_hra WELL DRILLING UNIT
Airiest cal/rum.with stem set at ft for hrs
N Artesian flow v P m Date - r// 1, N
it Temperature ofwaie_Was a chemical analysis made' ❑Yes ❑No Sort Dar/1$-` yef Completed Dam 30Z Pee Z03
N
O WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all
N Washington well construction standards.Materials used and the information reported above are true to my best kmwkdgc and bell
.C14 ,pp I ' ' east Irt
F /ea Chiller ❑Evgmea ❑Tamee Name(Prim /`d/'/ N Dnlhng Company £VEc' "u l/�
D)rilkr grneer/Cratnee Si gmmtm __ Address r140'T Jon 1/w• 0102i t).AreI ppp
Dnller or Trainee Latent No. U/A a .S City,Slate,Zip 311E(4az 1 WFL • f07D9
Contractor's
Uali a Iasi Dam 1 a 3J •o V trainee,licenseddriller's RmtrEtoon No
Signs u.nod License nth Ecology is an Equal Oppomamty Employer ECY 050-1-20(Rev 4/01)
Vanguard Laboratory
2635 Parkmont lane SW
Olympia.WA 98502
360,967 7010
VAN GUAR Report of Laboratory Analysis
LABORATORY
Collected by:
American Pump and Drilling Matrix Drinking Water
360-754-0867 laboratory ID; V230826-10
Sampling Address: Date Sampled: 8/2523 13'.15
10361 Washington 106 Date Received: 82623 8:00
Lnion,WA 98592 Date Reported: 8282023
Sample ID: Joe Shriner
Analysis Result SDRI, M( I. Units I)1 Date Analyzed
Total Coliform& Na.cull by SN 9223B(IDEXX) Ranch IDA/230826-I0 Analyst Vl
Colnorm.Total Negative I 1 MPXA001nt. 1 8262317.10
E.cob Negative 1 I MPN/100 ml. I 8,262317.10
Note¢
MIN M.m Probable Number
ppm parts per million
nd Ion seed Reviewed by Robert Smalling Chemist on OS/28/2023
n n.nit apphmmc
SDK Stale Driealn,,Repotiap Iunit Approved by Jeri Johnson,Operations Manager on o8282023
IJulion lacier
i1! 1776LSQOtl
NCL Vincuaum Cnmm�nnoni laud S`��! WORATOry Page I of 1
Samples e di cep:able conditionJl esultfsi in Oils
sport relate I)to de poor af the. plefsl doled.All ma- lerf imed consistent
the Du aliry Assurance program of Vanguard laboratory Please contact the laboratoryR/oe should have any 9ueuons about the result.
2635 Pat kmonl Ln SW,Suite A.Olympia WA 98502 Office:360 967.7010 I testing(uivanguatdlaboralory.com
ss nw.vanguardlabaratory.mm
2202931 MASON CO WA
10/03'2023 09:05 AM NOTCE
GREGORY STORMRNS #191380 Rec Fee. $204 50 Pages. 2
111111l')III]I1111111111 IIIII IIII IIII I!III III I IIIIIII III liii 11111]tII Ilil
Return To
r v y sir r1pusvt $
162-5 C J 1 n l r y tuo cot d r, S a
Lx.�/ Mr/�icy / kV 4 q/ Sb)
Grantor(s): (1)(-1n2Ljf9f j TTc>C6'v1 411 S (2) Cr r 515 ✓lv' S fnf11/1s;I
Grantee(s): (1) PUBLIC 1 2 j� .1 n ' - �1n
Legal Description(1) —_LOil2c6)_ 4t,� CAA t,
(Abbreviated form:i.e. lot, neck, plat brsedtion, township, range)
Assessor's Tax Parcel: (1) ?-1 Z . 5 - 5 _L- G 0 'Z
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) '3 2 2- 2- - 5 L- O O 6 2- €)
Tax Parcel: (Connection 2) S - - 2- 2 5 - 5 t - 0 d c.> 3 0
The system owner is responsible for
keeping this system in compliance.
The name of the water system is: 4-r liC4L. Beach CE-14 7e,✓tooi lets'
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. q ,4t//
Dated on this ( day of i tl , 20 23.
Signature f Grantor(s):
(1) J9 J (2) LIPMNvl_!'AD �W✓�—'
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 aci day of n AA-CrSA-
' 20d=,
�xra,A-✓r- rtsreA.S1-w mc+nspersonally appeared before me, who is known to be
signer of a above instrument, and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and year last above written.
_0% µie IN Notary Public in and for the State of shington,
JOMMwon % residing at I v
oi44v • My commission expires: u} —IG -2c5
Eu 75311
i 1{� % o'
/i F�xnw.„w' �G
p1i1 1WAS04-
Page 2 of 2
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