HomeMy WebLinkAboutWEL2023-00051 - WEL Application, Design, Letter - 9/27/2023 MASON COUNTY 415N 6TH STREET SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
RI BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
LOPEZ JAVIER & GRACIELA
460 SE FIREWEED RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00051
110 E Passage View Rd
221277590152
The 2-party water system, Oscar's (221277590152/221277590152), 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,
'12
David Anderson
Environmental Health Specialist
Mason County Environmental Health
11%
_` MASON COU (TYOCT. 0 3 7023 Date Received a .,1 . is
Ii„AL.:. l COMMUNITY 1 f ce '19'SD �Rm R�l.�e
ci4 au le .Pb ,r m Health,c Communise Health C 5 • 11
4I, N.fi Street.(Bid NI-sh It WA965R4 WEL � '17 . G 6651
Sheha r 160427-9670 x400 IleLry r 360-2754469 x400 Lima 260-111-5260 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
tactCAc 1-0007i Sd0 —708 MAILING -MP/
ADDRESS-STREET,CITY STATE.
6o SE /-;rcu/ccs - , 5llo1 A ( lf✓} %9&8�/
SITE ADDRESS-STREET,CITY,ST�A•TE,ZIP
1IDYEELR EBR1WCLLVTE) View) RJ-, Stiel A ILIA79599
aai27-7c-1OIsa
SECONDARY PAR EL UMBER OF APPLI ABLE)
WATER SOURCE/ SOURCE TYPE PARCEL 1 LOT sin PARCEL 2 LOT SIZE
❑Sew kxisting *ell ❑ Spring /0
47
PROPOSED WATER SYSTEM NAME IREOUIRED)
O SUY S
PROJECT DE IPTION
Tito pJo ,E . er u,e41
DIRECTIONS TOs CONDITIONS t� '/ _ J
uiA--- , R— E I r.r.�-ertn Y1o(a . Ia .� nwo s ratt o.�t d-me_,
Rrt4e ' 6— l AIrM Tc'nttc r. l ^ /�' Itt1//�prAticeF
/Jt1 I „Ai-) J -- mn4n E asict ye . vest) a r ra4/lG.Site Plan: (may also be attached) 71.
(property boundaries,structures well site w1100'radius driveways.roads,seplidsewer components and lines,easements,etc_.)
hit
Submittals Checklist: (these additional items will be required for approval)
/
[2' 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)
,2 tice 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: I IP13 2021
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ 73 E Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ X ❑ 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?
K ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
14 ❑ ❑ Is the well cap satisfactory?
p ❑ ❑ Screered and vented? w
..,,SS ❑ The well casing extends 11 above level ground/concrete slab? (circle one)
dry ❑ ❑ Is there evidence of a surface seal? tat: (47.276'2021
10 ❑ ❑ Does the seal appear adequate? urn; —W. P07('t$ '
❑ I� ❑ Is a variance necessary for well site approval? BUY lei
7_ 'SAC:
Comments J
pe Pass ❑ Fail Inspector /v Date /(////Z,//i
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file? n!Y" '7/�
����!!!! If NO, date of Capacity Test 1 Cf?/q/ 72 Driller kat nKill GPM ( t�
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ! ° t�
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZU/tS 9'7
7 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments/ /{ / / 7,.1
Ip Approved ❑ Denied Reviewer / Date `l/l( O( L(/�j
/ 1.Endings in this review reflect observed conditions as they existed on the day of the site inspection. No claim i.s made, express
or implied of thePoore success or failure of this system Iit'll site approval does not constitute water ss/enr approval. ll'ater
Sxstem approval ie a two-part process.
All proposed connections to new wells are subject tawnier adequacy requirements at time of building permit per Ii('C'6 68.
Baler usage resiriatmtc and additional fees may apply toall new wells drilled quer Annuity I9th, 2018 per E.S.SB 6091.
Revised: 10'132021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
^ --(3 ) S -. aoC7sL
- . .ton County Environmental Health
2008 Lakeridge Dr. SW t Olympia,WA 98502
sags. - _ gryy3 360867-2631
nm" gild fssaa-
C'I LIFORM BACTERIA ANALYSIS
� Time Sample County
Collected
I ❑AM
IS PM
Lionin Cry Year •
Type of Water System(check only one box) 0 Prvate Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems—Provide from Water Faclities Inventory(WFI}.
ID
System Name:
Contact Persons
Day Phone.( ) Cell Phone.( )
E-mail. I Eve.Phone:( )
Send result to:(Pent l l name,address and LPcode or emar.address)
SAMPLE INFORMATION
Sample collected by(name):
Specific location or address where sample collected: Special Instructions or comments'.
Type of Sample(must check only one box of#1 through e4 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 Chlonne Residual:Total Free
❑E toll—OWR(A/P)
❑Fecal—sodas owl sprngs lnumeamry Unsatisfactory routine lab number:
FitlereC Yes No
❑Assessment Monitoring(NP) Unsatisfactory routine collect date.
❑other L /
IBI I J
4.❑Sample Collected for Information Only
Investigative _ Construction i Repairs_ Other__
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colton Reese's:and I C Satisfactory
❑Ecoll present ❑Ecoli absent
' No Coliform detected
Replacement Sample Required:
0 Sample too cid(>30 hours) D TNTC ❑
Bacterial Density Results:Total Coliform_ 1100mL Ecoll I100m1.
Fecal Coliform 1100m1 Enlerococci /100 mL
Method Code SM 9223E ❑SM 9222D Date and lime Received.
❑SId 9215E 0 Enteroler10
Data and Time Analyzed t a Date Reported:
sample Ft mber:1:1011numbe,plus leeeien) Lab Use Only:
D 8 0
---
DOH Forma a1-319Ire.hed antes
•
WATER WELL REPORT 'LA DEPA Ri ME NT Of Notice of Intent No. WE47143
ECOLOGY Unique Ecology Well ID Tag No. BN)(192
Type of Work At Slate of Washington o Construction
Site Well Name(if more than one well).
❑ Dcconuniuipn =LY. Original imulladon NOI No. Water Right Permit/Certificate No.
Proposed Use: O• Domestic 0 hWmoial 0 Municipal property Owner Name GraciCla Lopez
0 Dewatenng O Irrigation 0 Test Well 0 Other Well Street Address 110 Passage View Rd, _
Construction Type: Method: UV Shelton CountyMason
el New well 0 Alteration G Driven D Jetted 0 Cable tool try
❑I)eeperdng 0 Other 0 Dig la Air- 0 Mud-Ratay Tux Parcel No. 22127-75-90152
Dimensions: Diameter of boring 6 m.1e 196 fl. Was a variance approved for this well''/ ❑Yes 17 No
Depth of completed well 196 n.
Construction Dee•IDI WallIf yes,what was the variance for'/
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
EIO 8 MO 193 .025 in. it I ❑ EIO Location(see instructions on page 2): O W WM or❑EWM
❑ I ❑ in in ❑ I 0 O 1 ❑ SE rL-'L of the SE n;Section 27 Township 21N Range 2W
C] i ❑ _in in. IJ I ❑ ❑ I D I At itude(Example'47.12345) 47.276318
longitude(Example-120.12345):122.909663
Perforations: ❑Yee allo Type of fPerfo"mar used Drillers Ing/Comlruetlan or Demmmiasiatl Procedure
PerortedRo S beof ground
Perforations to bym Formation:Describe by color.chance of material and strumpet and the kind end
Perforated 6omflro A.below gouMralW'u'e nature of the marmot in each layer penetrated,wish et least one entry for each change of
gereew: 0 Yea 0 No M K-Packer t—> Depth 190 it information. Use adtilional sheets if necessary.
Manufacturer's Name Alloy Machine Works Material From To
Type Stainless Slotted Model No and gravel 0 41
Diameter 5_ Slot Las.018 in from 191 ft. 196 A Brown silty sand.
Diameter_ Slot aim in.from A to fl. Gray silly sand and gravel 41 45
Sand/Filter park:O Yes I]No size of pack material n: Brown silly sand and gravel 45 54
Materials placed from A.to ft Gray silty sand and gravel 54 70
Gray clay 70 81
Surface Seal: la Yes 0 No ro what depth? 20 a. Gray sill 81 110
Manner used m seal Bentonite Chips Brown sill 110 112
Did any shad contain unusable water, 0 Yes El No
Type of water? Depth of strata Brown silty sand and pea gravel 112 115
Method of scaling male oft Gray silly clay 115 117
Brown peat 117 122
Pomp: Manufacturer's Name TYPe'. Gray clay and gravel 122 127
11.P. Pump nuke depth: ft. Designed flow rate: gpm Gra nil sand and•ravel 127 133 _ .
Water Levels: Landeurlea elevalion above mean ace level 180 a. Gray medium sand,some gravel 133 149
Slick-up of top of well casing 1 ft above mound sus face Black sharp gravel fine gray sand sill 149 168
Static nip. rc
tenet 156 A.below lop of veIl casing Due 1/1]/22 Gray silt 168 I8S
Artesian pressure lbs.per square inch Date
173
Ancnan watern controlled by (cep,salve,cm) Black sharp gravel,medium gray sand,wet 173 182
Black gravel,medium black sand,loose,water 182 196
well Testa:
Was a pumping rest perk-lolled" e❑No O Yes O bywhomt
Yield plan wins it drawdownafter bt u
Yield gpm with _n drawdownafter s
Yield gpm with ft drnnd"w bra
nv at e bar
Recovery data(time—ssr ten Puasp it mmNar-water last mcmwed horn well
lop to„at„Wye!)
Tirrr Waier level Time Water Level Time Water Level
Dare of pumphrg test _
Baler tee: gpm wdh It drnwdown after ass
Aff sl 20 2pm withset at 185 Ii for 1 hum pate 1/17/22
Artesian flow gpm
Tcinperalure of water 49 ^F Was a chemical analysis made? ❑Yes MNo Start Dale 1/14/22 Completed Date 1/17/22
WELL CONSTRI:QION CERTIFICATION: I constructed and/or accept responsibility for construction of this Nye,and its compliance with all Washington well
construction standards.Materials used and the information reported above are true to my best knowledge and belief.
❑Driller❑Trainee❑PE—Print Name Josh Koepp Drilling Company Arcadia Drilling Inc.
Signature Address PO Box 1790
license No. 2874 a !//fr City,State,Zip Shelton,WA 98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature _ Registration No.ARCADDI098K1 Date 1/17122
ECY 050-I-2C(Rev 09/18) If you need this document in an allemareferncal.p/ease call the Water Resources Program at 360-407-6872
Persons with hearing'um can call]/l for Washington Relay.Senace Pers05310hh a speech disabibry can pall 8]]d33-6341.
2202599 MASON CO WA
0912512O23 03:1e PM NOTLE
LOPEZ $191124 Rec Fae- 5234 50 Pages 2
Return To HIM
I -YrieA erg FZer 2 /y
9/66 sE .re, ,ceec(' Y�-
$AP,(* u / 79 `frCcy
Grantor(s): (1) 5 j?YC[e% 20 w,2 (2)
Grantee(s): (1) PUBLIC Legal Description (1) T7* IS-$o-f D„-oea v(f.Sa Ai 8 of s ( yr2
(Abbreviated tour:i.e. lot. lock, plat or section, township. range)
Assessor's Tax Parcel: (1)2_Z I Z 7 -2 1Q j--yam2
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 l) a 2 ) ).Z-_a- It 2 °R1-
Tax Parcel: (Connection 2) _ !I "aZ- 7S' - 0 / yy
The system owner is responsible for', eeeping this system in compliance.
The name of the water system is: (J.$ en Y !C
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 day of , 20_
Signature of Grantor(s
(1)G ) . (2)
Page 1 of 2
State of Washington
County of Mason
I,the undersigned, a Notary Public i and for the above named County and State, do hereby
certify/ that on this day of T 20 23,
a attuict L z rsonally 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.
Vj
•`) V ECk i/f/ Notary Pu 'n a for the State of Washington,
S st on E• ..PL4* residing at
S.0...est-202e ti••, i My commission expires.. (J
E<:u f /WY
�0`' ••
Page 2 of 2
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