HomeMy WebLinkAboutWEL2023-00047 - WEL Application, Design, Letter - 9/1/2023 A . MASON COUNTY 95"6TM STREET,
SHELTON, 584 SHELTON: -06%0, EXT 400
BELFAIR-.360-275-4467,EXT 400
Public Health & Human Services ELMA 360-482-5269,EXT 400
FAX:360-427-7787
CROMWELL TIMOTHY MJ & SUMMER R
1121 SE PHILLIPS RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00047
1121 SE Phillips Rd
320357500220
The 2-party water system, Cromwell Well (320357500220/320357500220), 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
SEPQB
MASON COUN • �73 "e "e°
COMMUNITY SER 'QED miselt 4: '
Burlding.Planning2wAnnmervalx II Community H N 1�
116 N 6 Sheet 1111.1 N)—Shl W19R>N VVEL Loan tcya
Shelf , 360 L9-9670 x4f t II Ita r 160-29 44fi 2400 I.In 40 1E2-5269 x1111 AAA
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
--r;,1a31-ti ET.CIT(aml,✓eIt 3CG - Yi9 -1yaI
MAILING ADDRESS-5
Ih se p<1i!Hp5 Roacty �� c )+cny I,✓a[s1r:�r }on 985,e't
SITE ADDRESS_STREET,CITY STATE ZIP q (/
I1LI S� Ph. It Roac( Stielfon) L% I;rvp >Lon / O p 51(9-
PRIMARY PARCEL NUMBER/WELL SITEI 3 20 S 5 7 5 0 L 2 G
SECONDARY PARCEL NUMBER(IF APPLICABLE) ( 3 20 3 5 7 5 00 2 20)
WATER SOURCE ❑Nev SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SQE
l3�I-xisting Well ❑ Spring 5 ac re 5 M/A (Ante)
PROPOSED WATER SYSTEM NAME(REQUIRED) / r,^.m LA/e. / V l
PROJECT DESCRIPTION Abu
11'
�91„9 an �lbC io of I^ I�rep t'ft)
DIRECTIONS TO SITE/CONDITIONS Veil(
heal
/
is 54raI,k+ In -(1-c44 04 ycM a5 juw
C2n'le op -file ✓e . Ale get♦•e. 4o gags.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100 radius,driveways,roads,septic/sewer components and lines easements,etc..)
Sze. al aciac
IT; F.1
0I 2023
Submittals Checklist: (these additional items will be required for approval)
d 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)
Ere 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 Oil 3/202I
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection: { ,
YES NO NA SD\ -b /hit
1r ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
r �7I (drainfields, tanks, buildings; indicate distance on plot plan)
❑ W ❑ 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?
4. ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
j ❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? I '
❑ The well casing extends /7 above level ground/concrete slab? (circle one)
10 ❑ ❑ Is there evidence of a surface seal? Ltd'. y} I ?-)$91/1
/{y�� f0 ❑ Does the seal appear adequate? LOVI : "(ZSI O19mti
r I_I I�' ❑ Is a variance necessary for well site approval? `r49' Pon y9 T
Comments d
KO///R'J Pass ❑ Fail Inspector
1 i Date 9/7 7L�' 3
/Review Step 2: Two-Party Review:
Y!S NO NA
f/Wd ❑ ❑ Water Well Report with adequate pump test on file? /y aPM
If NO, date of Capacity Test C8/70o v Driller T Ib$ 0111 t 7 GPM I y
3❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test si70
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 72Q IRS
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments /��7 Approved ❑ Denied Reviewer z��21rf ) _ Date //1 / ��(' ZJ/I;indings in Ins review reflect observed conditions asthey existed on the day the site inspection Ad claimclim is made express
or implied of the future.success or failure f this system. Well site approval does not constitute water system approvat Water
System approval is a two-part process.
All proposed connections to new wells are subject to loiter adequacy requirements at time of building permit per:WC 6.68
!rarer¢sage restrictions and additional fees map apply to all new wells drilled after January 19'h, 2018 per FSSH 6091.
Revised: 10.''13/202I
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
Thurston County Environmental Health
2000 Lakeridge Dr.SW 0 Olympia,WA 98502
360 867-2631
TIIMRSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
i <<'( ' 4
35 -M % p'i r1.<c)
Monty Day Yeni
Type of Water System(check only one box) 34rivate Household
❑Group A ❑Group B ❑Other
Group A end Group B Systems-Provide from Water Facilities Inventory(WA):
IDq -- --- ...
System Name: �°-
Contact Person: Its') -I/t I Yq y_va II J
Day Phone'.( 6j) j/J.--s2 Cell Phone-(</0)9/t 7y671
E-mat. i�r'LI 1-1f�. Cl�'011n u.,.r � r' ups Eve Phone'(360)7,9--Z`7QI
Send resu Is loaPlinl full neap.address and zip cos* email addrksel r
PM s w r Jf-e ndi r01 . C diN
SAMPLE INFORMATION
Sample collected by(name):
Specific location or address where sari le collected: Special instructions or comments.
fiL1 SL Ii. ;)12 ' k]Vp{ !'a. {� .,rill
Type of Sample(must check only one tux ofa1 through ate listed bebw)
1.Ly Routine Distribution Sample 2.Repeat Sample(after onset.routine)
Chlorinated Yes Now"" 0 Distribution System
Chlonne Residual Total.__Free- Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.cols-GWR(NP)
❑Focal-sun®e ewt srvws(nurnurulioni Unsatisfactory rouline lab number:
Filtered Yes____No._. _. .
I ❑Assessment Monitoring(NP) Unsatisfactory routine collect date
0other I
s
4.0 Sample Collected for Information Only I ,I
4) ,/
Investigative_ Construction l Repairs Other w:(I /I rr.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Califon Present and Pi Satisfactory
❑Ecoli present ❑Ecol;absent `r Colllorm detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 INTO ❑_____._—..._..
Bacterial Density Results'.Total colilurm — Ilooml. Eanti_.__._-.1100m1.
Fecal Coliform Ii00m1 Enterococci /100 ml.
Method Code SM 92238 OSM 9222D Dale andnY Tin Received
] .- -
❑SM92156 0 Enterolertm -' 2
Dale and Time Analyzed l'J :. i / Dalo Report:.
Sample Nmw.a(DON wmMt pups rye 6 es) Lab Use Oily'.
0 8 0 ... [.1
DOE gnipsli 3191 se ylel — — I y'D
,- WATER
�. MANAGEMENT 1515 80th St. E.
Tacoma, WA 98404
an LABORATORIES uxic. (253)531-3121
Chemistry - Report of Analysis
Date Collected:06.28.2022 System Group Type:(circle one) A B Other
Water System ID Number. N/A System Name: Tim Cromwell
Lab Number/Sample Number: 089/03963 County: Mason
Sample Location:Wellhead Source Number(s):(list all sources if blended or composked)
Sample Purpose:(check appropriate box) Date Received:06-29-2022
RC-Routine/Compliance(satisfies monitoring requirements) Date Reported:07-15-2022
Ej C-Confirmation(confirmation of chemical result)"
Li1-Investigative(does not satisfy monitoring requirements)
Supervisor Initials:
• O-Other(specify-does not satisfy monitoring requirements)
Sample Composition:(check appropriate box) Sample Type:(check one) ® Pre-treatment/Untreated(Raw)
• S-Single Source EjPost-treatment(Finished)
• B-Blended(Ust source numbers in"Source Number field) ❑ Unknown or Other
▪ C-Composite(list source numbers in"Source Number field)
D-Distribution Sample Sample Collected by: Jay
Phone Number:360-876-4421
Send Report&BIII to: Nicholson Drilling Comments:
PO Box 123
Port Orchard WA 98366
ANALYTICAL RESULTS
DOH# ANALYTE DATA RESULT SDRL TRIGGER MCL UNITS EXCEED DATE METHOD!
QUALIFIER MCL? ANALYZED INITIALS
0004 Arsenic — <0.0010 0.001 0.010 0.010 mg/L No 07-01-2022 200.8/SS
0020 Nitrate-N — <0.20 0.5 5.0 10,0 mg/L No 06-29-2022 300.0/EW
NOTES. - —
•Confimation:Indude the original lab number,sample number,and collection date of original sample in either comment section.
—No exisiting value.
ANALYTE:The name of an analyte being tested for.
DATA OUAUFIER:Asymbol or letter to denote addlional infomutlon about the result.
DOHS:Department assigned analyte number.
EXCEED MCL:(Maximum Contamination Levefj:Marked if the contaminant amount exceeds the.MCL under chapters 246290
and 246-291 WAC.Pease contact the department's drinking water regional office M your area to determine followw:up actions
METHOD/INITIALS:Analytical method used.I Initials of the analyst that performed the analysts
mgll:milligrams per liter or pans per million
RESULT:The laboratory reported result.
SDRL:(Stale Detection Repotting Unit):The minimum reportable detection of an analyte as established by the Department
of Health
TRIGGER:The department's drinking water response levet Systems with contamhants detected at concentrations In excess of
this Wei may be required to take additional samples or monitor more frequency.Please contact the departments drinking water
regional office In your area for fuller Information
LAB COMMENTS
a WATER WELL REPORT N"dceoe ntentNn w/S7/D8Z
Fi"o'i'ob i Original&1st copy-Ecology,2nd copy-owner,3rd copy-driller a14m 7138
Unique Ecology Well ID Tag No. /s
Constructioo/Dtca mussion('.x"in riffle) T WfE1.C�
ai Construction Water Right Permit No. exe1'MlB
i 0 Decommission ORIGINAL CONSTRUCTION Nmice �e,-s ,A
12 le23n7 of;went Number Property Owner Name4FF )4itOE&)
N PROPOSED USE: gDomesfic ❑Industrial ❑Municipal
d' L7 Well Sued Address ))2.1 S t E ON/LUGS RO
0 DeWater lnigatiot °Test Well Dower ` .sw.� • '
N TYPE OF WORK: Owners number of well(if more than one) ' City 5/dF.t.�AaJ�/� Co22unl!ty. ��
N eve Well °Reconditioned Method:°Dug °Bored °Driven
a�
�,v Location l/a-1/4 NVII4 Sec32 Twn/B/L R 3 EWM cycle
L (]deepened ❑Cable �Roury ❑Jdtcd TsuLong: Lat Deg Lat Min/Sec Wtw' ne
« DIMENSIONS: Diameter of well eF inches,drilled /6,51' ft on still
C Depth of completed well ICI _ft. REQUIRED) lung Deg /See Long hat
Tax Parcel No. 3 Z0 35-75 —On ZZ coC CONSTRUCTION DETAILS
C Caring Sweided Diam.from IV ft.toahR R CONSTRUCTION OR DECOMMISSION PROCEDURE -
R 'mulled' ❑Liner installed Diam.from nn
" R.m ft. Poan n:Describe by color,character.size of notarial apd structure.and the
kind and d nature of the material in each stratum penetrated,with at lust one
Threaded __ Diam.from ft.to B' entry for each change of information Indicate all water encountered
F Perforations: °Yes%
No (USE ADDITIONAL SHEETS IF NECESSARY.)
C Type or perforator used MATERIAL FROM , TO .
" SizEofperrs_in.er _n.rams no.ofpors ' from fi.m___n Wtu SOIL t )J .5 ASO 0 /
5 srreem:%ves ❑Nn EuO --- *A.0 5,Is o W/ S/LT / /e
Type Manufacturer's Name r SAa1b -S/lAa (nAp vat,
O Type /a//Ca Model No. I) ,SAIk to Z I
CDiam. Slot Sim //n front_[��Rm AO/ ft. Wfl�
co Diam. Slot Size from ft.to ft. GFiYNFi ee TAN 5*MO
RI Gravel/Filter packed: ❑Yes gNo 0 Size of gravelfsand lvat.WEL `Lq.(4y ZI 3b
Q Materials placed from ft.to ft
Surface Seal: PlYes °No To what depth? 20 ft 1-6441EA%E'O (nb&Y 540 a
IS Materials usedinseal._ $CNToN/TP.. FjttAatEL.-LukY 3/a• 79
Did any strata contain unusable water? Dyes gNo
11 Type of water? Depth of strata //4vvr( Cane &le ves—
Method of sealing strata off
SP•d 71LI� • 79 )0/
a— PUMP: Manufacturers Name EOO✓LOS
Trp : Sv» H.P. / •
/.AEY SAa10 kg Lk-/4Y /0) /Z(o
WATER LEVELS: Land surface elevation above mean sea level ft.
1- Static level_./ /4 ft.below top of well Date 6-3-0�' naa 2D
ZArtesian pressure lbs.per square inch Date Sf4/.YO -�/LT'�) S�YnfiO ]..(o ///�
to water is controlled by
w ap,vave.etc.) GAn GL.W /35 /Y3
o WELL TESTS: Drawdown is amount water level is lowered below static level.
Si Was a pump test made?°Yes No If yes,by whom?
a Yield--:_zavndo.with ft.dmwdown after hrs. ♦We S/4te 5/;b7 W/GA<WFL. /�f3 /oZ
Ot Yield. __gallnvn.with ft.drawdown after Ns.
OYield._�allmin.with ft.drawdown after hrs. /_a a.✓ w I c y
O Recovery data(time token as zero when pwnp turned off)(water level measured from (%/Y�s'T�Y' !
LU well top no water level)
- Time Water Level Time Water Level Time Water Level
0
C
CI ��- -.-r
E aeof est IO� J �r/T
Bailer test /k#-_geimmin.with // ft.drawdown afterafter_Z_Ius.
t Airiest ERAS.with stem set at ft.for .I Ins t
O. Artesian flow e.o.m. Dale
Start Dam tS-26-Oai Completed 6- 3-04
CDTemperature of water Was a chemical analysis made? cJ'es °No
CI WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all
W Washington well construction standards.Materials used and the information reported above are true to mya best knowledge and belief.
HgDfiller °Engineer °Trainee Name(PYfRa h A _ Drilling Company /)n'1 S ;VFW_ /!/1-ILI IA/t1
Driller/Engineer/Trainee Signal — 90 1$6ar `f3 (o -
Driller or Trainee License No. C , e,Zip Ett7 .0 1.-Ini1 f Vt (.444 /SSY0
If trainee,licensed driller's "' — Contractor'son No /�S WF/3/ �n�//—O�
JAN 0 4 200&g T ate
$Igra9tnre and License no. ^'—.."""'.0—....". Ecology is an Foul Opportunity Employer. ECY 050-1-20(Rev 4/01) -
Wash iupon Slate
r1__.......- . _ - "
2201851 MASON CO WA
I�Etnr/l TO 09/0B/2023 10.12 AM NOTCE
CROMWELL N1905519 Rec Fee. $204.50 Pages! 2
rmo,fiy (to n'' WeIl IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
•
IU S6 Vh;mps Road
Shell-on L✓fl 9r581i •
-
0n u23
Grantor(s): (1) f Hy GY011viw41 , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) 5 35 — T Z0 — R 3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 0 3 5 - 7 5 - 0 0 2 2 0
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 Q 3 5 - 7 5 - O a 2 y 0
Tax Parcel: (Connection 2) 3 Z- Q .3 5 - 7 5 - 0 0 2- v o
The system owner is responsible for keeping this system in compliance.t �14 The name of the water system is: C r O inn k L I I Pi I
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. e'+A
Dated on this 0 day of 4.J2temke/;20 Z 3.
Signature -Grantor(s) � y�f(.
(1) //!/,y //./ �'YVIV 42)
c Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a4Kotary Public in and� �for�the�above named County and State, do hereby
certify that on this 9 day of _«____ , 20'Z3,
IR {k..j CVoMwttl personally 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.
'I
aa0011t f ,� Notary Public in and for the State of Washington,
Se:. residing at So✓• Co,'"
My commission expires: 11(Z-17.A 2-6
• •NOtARY•• a
1
or
moo
Page 2 of 2
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