HomeMy WebLinkAboutWEL2023-00052 - WEL Application, Design, Letter MASON COUNTY 415N 6H STREET, ,WA EXT 584
400
H ELTON. N, EXT 36Ha27
S
LI BELFAIR 360 275 4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT400
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
MASON COUNTY Date
R`w' 1 O _ 2
I _ r `I COMMUNITY SERVICES GY()�^1 Amnun K. / t
\�/ BU Iting.Pbnn.g,Environmental Health,Cammunry Health //��//..''��
415 N6'"SIred.(Bldg A)-Shelton.wA 9S584 WEL ;1,2� _OccD5 )_-•
Shelton a6042)-9670 x4)0 Melba- 160-2754467 x400 Elma'.160-082- 269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT AXONE
MAILING ADDRESS-STREET,CITY,STATE,ZIP
10 I C Y `-/L l 9 ) x 7 C7 ' y )/
SITE ADDRESS-STREET CITY STATE.ZIP
PRIMARY PARCEL NUMBER(WELL SITE)
.i 2C2.ZC — C ( — cm'l( i
SECONDARY PARCEL NUMBER BF APPLICABLE)
37Z75-5/ - coo30
WATER SOURCE SOURCE TYPE PARCEL I LOT SZE PARCEL 2 LOT SZE
❑ New pi,,Fxtsting la.,Well ❑ Spring _:-. N(-1,-..' c _• .:J i.: <
PROPOSED WATER SYSTEM NAME I REQUIRED) � �
/2�// , l LL/i r '-''-0--/-1it,i ✓ 1
PROJECT DESCRIPTION
( -' 'III' . ' Jr/ '//." c. r
DIRECTIONS TO SITE/CONDITIONS I
LUF I
/ (' - L. . r I ` L n r L . , x-.. //2 61/. ✓/Ai C- _t /, :-
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100 radius,driveways,roads,septic/sewer components and lines,easements,etc...)
/u Z1 C 1-€i:/ J5 -L, 7
OCT a D sued
RECEIVED
I
3 ^ls
kil
Submittals Checklist: (these additional items will be required for approval)
jSatisfactory 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)
fxr 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'. 1 011 3 2 02 1
Page 1 of 2
Staff Use Only
Review Step 1: Well Site lgsp fiction: _571ti fq k 7 f
YES NO NA IfuiCe 65 —DF >/00
X ❑ ❑ 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 fuel Cadius of the water source? If so, is road private, County or ate.
What is distance to ROW? L 3
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
of ❑ ❑ Screened and vented? tt
❑ The well casing extends t O above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Leg-: 1/?.36 32167
th -123.00 S 2S0$'
0�/ ❑ Does the seal appear adequate? 72y:ABQZl6
❑ W 0 Is a variance necessary for well site approval?
Comments
Pass ❑ Fail Inspector IN, _ Date �' 17/7� G�
Review Step 2: Two-Party Review:
YES, NO NA
Uf ❑ ❑ Water Well Report with adequate pump test on file? 7
,,ttt��� If NO,date of Capacity Test /200/201 Driller h(I GPM JQ
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 8(2100Z)
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN Z202-93
❑ 0 System appears adequate to serve 2 single-family residences based on information provided?
Comments
;kr
Approved ❑ Denied Reviewer L/// Date 1p/ ?Y/70 L3
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 fuure success or failure of this system. Well site approval does not constitute water system approval. Water
System approval lr a two-part process.
All proposed conrtection,s 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 Janrmrp 19rh, 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
__
WE C
WATER WELL REPORT NoticetoflnentNo. W 125249
y[a ri'''i Ongmal&1st copy-Ecology,2nd copy-owner,3rd copy-driller
Unique Ecology Well ID Tag No AaQ 7_1
Conslruetion/Decomnlisston CC in nude)
a.i 0 Construction Water Right Pent No.
G 0 Deconnusston ORIGINAL CONS IONTION Nonce f(,, p I
CL iU93ra otwentNundnr in 125.,T Rg propeny Owner Name &AlN [ K. S//aanhi
406
at
gt PROPOSED USE: Domestic 0 Industrial ❑Municipal Well Street Address /0 S50 I G. log 1t�Sv
0 DeWater ['Irrigation Teat Well Daher /sA
=y city ON(N(T(O& County: III asol
TYPEf OF WORK: Owner's number of well(if more than me) Licano 1 V ra`I/4-1/4C�/4 c 2c Twon_ Ps circle EWM
1/1 &New Well ID Reconditioned Method 0 Dug 0 Bored 0 Driven
❑Deepened Cable lxNnn
a• DIMENSIONS: Diameter of well 'oche:,anucdO 9 Oft (s,t,r still Deg fit Min/Sec
CO
C DepOofcompleted well •pO fl REQUIRED) Long Deg_ Long PhISec _
C CONSTRUCTION DETAILS / /, t
Tax Parcel No. I5a.72 5 ' 51 - OOO 21
O Casing Welded (n ie,ZSa Diva from+lg ft to 7d�.'{I CONSTRUCTION OR DECOMMISSION PROCEDURE
03 1nsW4d: Dram from R to ft Formation-Describe by color,chancier.size of material and structure,and the
E A ❑ThtadeLiner installed kind and name of the material m each stratum penetrated,with at least one
O'IheadW Dam from ft m_ fl entry for each change of information Indicate all water encountered
Q Perforations: ❑Yes gNo (USE ADDITIONAL SHEETS IP NECESSARY)
C per Type offoratorused - - _ _ MATERIAL _ FROM TO _ -
C 1
a) SIZE of perfs_mv by�n and no of profs from ft to R SR. J+6t�AUCL +'S O. L
✓ Sterna:jilYes ❑No O K-Pat Location toy I Dose Menu") D
i Manufacturer's Name Fen.'r.a3..I lb a/ �/
1 Type 30 4 S S Model No Cowvi l w: d
Dram 15 Slot Sae ,3O from SO ft to el ft .C+e^•a.ne4 .SA--dtGR• I
astham S so,size 1t6 Rote F15 ftto 7I ft IStasdeat ny CL Handheaw4 if 2-5
as GravevFRter packed: DYes I No D Sass ofgnvellsmd
ea Materials placed fro It to ft ei Ac .0,L -r" /L CitrTr. -
0 Surface Seal: (y'Yes CINo To what depth? 1SI ft fJ/N to I/GRy/1444 yets 25 35
LMatenals used in sem Lawn 1 RC...1Ln.‘1-'`L rA:pe -sit
+• Did any strata contain unusable water Dyes cgNo Hto &Ana+ G RAua L-)C0 'BLeS
at Type of water' Depth'Aswan Lop Ste Su:l- 15'
C Method ofseahng strata oft
m CotatP bag; )3LE 35 60
PUMP: Manufacturer's Name
U Type. H P paw: I
WATER LEVELS: land-surface elevation above mean sea lcv ft rionite C SAr.d/ts-Asti-0-Caf41g6-PS
I— Static level II ft be'oo,top ofwell pat'sou. zit i3 Ile FtY /4aane/ aRavin) t O G Sf
ZArtesian pressure lbs per square inch Date �O
in
water is controlled by N2o Se.s,dt6gAtrottC i S
ill (cap.valve,cm) /,-pose C'aLoe VA •`, b
O WELL TESTS: Drawdown is amount water level is lowered below static level .SW C.- ///V r-T; etf SC 0Was a pump test made'Dyes ONo If yes,by whom'' A'
T Yield d un al/n -witb - - --ft drawdown after. - - - hat ray. >I
pYield__gal/mun with ft drawdown after hrs GRP u cC.+Cue y i H s
Yield, gal Dom with ft drawdown after his T car erg M aar./ .`yg' 0 1
O Recovery data(nine taken as zero when pump turned(water level mewaredfram
W well nip to water levee �. f. fii -
a- Time Water Level Time Water Level Time Water Level en
c IAN 0 7 2004
Y
=
YpI Date of rest DCOtl ran`,
C' an`,
�.m Bailer test 3O teal/nun with I ft drawdown after hrs WFIL DRILLING UNIT
r Autest gal/man.with stem set ft for his )�.N 1, i
O. Artesian flow pm Date Stan Date/)a' ye Completed Date 31 Dr.c. 4-a3
W Temperature of water Was a chemical analysis made' D Yes O No
O WELL CONSTRUCTION CERTIFICATION: I constricted and/or accept responsibility for constriction of this well,and as compliance with all
d Waslungton well construction standards.Materials used and the information reported above are true to my best knowledge and/ bbelie f'�
Roth N DrillingCompany gVE V-�1 .,l tt
I— ilkr/r DEngineer DTwmee Name(Pun[ y zajeao M1p01
Drilkr/Fnganeer/Trainee Sigrarur Address Lid
L .
I
1OLf),Ibttjr17 il 1 +oil
Driller or Trainee License No. IA/A aa4 S City,State,Zip v.k(n�nci 4 dIL1 • I Q 85'an
L1
Contractor's 1OSm-9 Date 1a -31 -o 3
v trained,licenseddrilln''s Registration No
signature and License no. Ecology is an Equal Opportunity Employer ECY 050-1-20(Rev 4N1)
Vanguard Laboratory
2635 Parkmont Lane SW
Olympia.WA 98502
360.967 7010
VANGUAR tp. Report of Laboratory Analysis
LABORATORY
Collected by:
American Pump and Drilling Matrix Drinking Water
360-754-7867 Laboratory ID: V230826-10
Sampling Address: Dale Sampled:8/25/23 13:15
10561 W ashinemn 106 Date Received: 82623 8.00
Onion WA 98592 Date Reported: 828:2023
Sample II): ,toe Shriner
Analcsis Result SURL MCI. lints DF Date Analy7cd
Total Colifornt&E.coil by SM 9223B(IDFXX1 Batch ID:V230826-10 Analyst.VJ
Cali font Total Negative 1 I MPS/100 nil. I 826/2317:10
P.uili Negative I I MPN/100m1. I 8262317:10
Notes
MPN Most Probable Number
ppnr parts per million
ad.oondmcct Reviewed by Robert Smalling Chemist on 08282023
ma oat applicable
MARL State DetectionRW.11111g Limit Approved by Pori Johnson,Operations Manager on 0828/2023
Dr.Dilation Faster t • 177015:2017
Page 1 of1
• r.rorrw
NCI. Mayinnm Comnmimm Level1•�d 4ygggon
Samples e reciiwed in acceptableconditionIhr results) IIIIS teportrelate h purtton otth pl 1.1 iested Allanalyses vela:p'f d CGI1L,ISICIII
ith the Q alt.Assurance prevrini or Vanguard)al:orates.Please contact Os laborato it yOLL should have any questions'let 'eddy
2635 Parktnont I SW.Suite A.Olympia WA 98502 I Office:360.967.70101 testing(ri vanguardlaboratory.cotn I
wttw.van guardlahoratup.cons
2202931 MASON CO WA
10103'2023 09-05 AM NOTCE
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11
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Grantor(s): (1) <-2rprjo r j S r ryla ll S (2) Cris / i r1« S•foir✓vl«,7 c
Grantee(s): (1)PUBLIC
Legal Description (1) _LBJ_r 12 F_ ?mill oil ?tat, v 7-4-ts
(Abbreviated form:i.e, lot, kook,plat orsedtion, township, range)
Assessor's Tax Parcel: (1) as "L 2. - 5 I - O G
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 / - U C O 2--
Tax Parcel: (Connection 2) "?- 2- 2- S - 5 ( - O d 0 3 c
The system owner is responsible for keeping this system in compliance.
The name of the water system is: �a+rtG iCK 13& Gin. 6J4 ter coo, kS
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 O'J1(q /I U day of t/ J'�/`, 20 23
Signature f Grantor(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 i9 day of (it&c ,. 0- , 20d3
Grr t1. strca Stly m+c-ns personally 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.
lNNlUllh ff `�O1� � 1/' CA1 cJ
SSE L Lie fib Notary Public in and for the State of VW.shington,
P .M""` `ar„'s'r '�..,, residing at 1 1A1
s sT't s� My commission expires: 4 -1ll -2 3 °
i 7531s g
s 4 +°.1�4 =
loe�F IWAS CS
Page 2 of 2
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