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HomeMy WebLinkAboutWEL2023-00008 - WEL Application, Design, Letter - 3/9/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, ,,WA 98584 0 SHELTON: 42 T EXT967 BELFAIR:360-275-4467, EXT 400 4 .Ih, Public Health & Human Services ELMA:360-482-5269, EXT 400 FAX:360-427-7787 Shauna Schacher 5380 SE Arcadia Rd SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00008 5380 SE Arcadia Rd 220303190030 The 2-party water system, AAD065 (20303190030/20303190040), 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 F., MASON COUNTY Date Receivetl �.. l- 111r''F 'I COMMUNITY SERVICES A R ze _nt Receive eY Building,Planning,Environmental HeelthCommunity Health • �, 415 N.61h Street,(Bldg 8)—Shelton,WA 98584 W E L O ' ,3--coo e Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT_ -, r PHONE O , 2-SO) (S- MAILING ADDRESS-STREET8IT©TATE3E �C � 3k,j- or �k S6 _ 3'1 ' I 1 SITE ADDRESS-STREET,CITY,STATE,ZIP S `J t PRIMARY PARCEL NUMBER(WELL SITE) 2.2030 - 31 - g00j SECONDARY PARCEL NUMBER(IF APPLICABLE) 22030 1 -q00 ctV WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑ New ,[xisting ,Well ❑ Spring S re__5 S acr<3 PROPOSED WATERSYSTEMNAME(REQUIRED) 1 ` NO D OeS PROJECT DESCRIPTION u4t GG.-.s 'itrc,i'lct,." 0I\ 5 C.C..o t�c1.C-1 1 Uv- t.\ C:::i DIRECTIONS TO SITE CONDITIONS _ r. t-- S ,\-.7., oJ\ nn ,Vr'L° C'. V.d . -+- +v rn ` icl h4 - Ii' '` E u r i 1'e tr\ Q 7 Site Plan: (may also be attached) (property boundaries.structures,well site yr/100'radius,driveways.roads,septic/sewer components and lines, easements,etc...) A \(---, � 1)\ T (MT rMAR 0 9 2023 I� BY Submittals Checklist: (these additional items will be required for approval) VSatisfactory Bacteriological sample (this may be deferred if well is not yet drilled) ell Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) otice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) la 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 Site Inspection: (Ili Van Peril 79 Rv bE YES NO NA PO IC, P,urn l 1 ' 1tW m tbi'te 59}t took 7 y' Ni 0 ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ Er ❑ 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? ,Qr ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) . O ,M 50 -�-• ❑ Is the well cap satisfactory? pi SC(' 0( fC4'l cacao F.; ❑ Screened and vented? �""�"� ❑ The well casing extends above level ground/concrete slab? (circle one) ,Er ❑ ❑ Is there evidence of a surface seal? jgj ❑ ❑ Does the seal appear adequate? ❑ X ❑ Is a variance necessary for well site approval? Comments -k .co,v..m t-y.1t�A� ,o �5 1�'1 L1 I'Il��l �j (CFI. - l i Z, YO-Yi`i to Tq Pass ❑ Fail Inspector / )j Date 3 /Zg/Z0 z 3 .. _ ..:aaae6111 ivs:w.iaea�aveegwc.TICC•1l�aM.SeM._:c ey<rmirlOSIM MOWRc .aarYralieliinrIMP aam®t Review Step 2: Two-Party Review: YES, NO NA ❑' ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test f/ /8[ .?Z ( Driller l iati ' G- 14.7 1700 6 PO ,,l ,r ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6/fYf ZGZZ (7 Q G /12y ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2%9 Lilo% ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer Date 7l70 l 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. Water System approval is a two-part process. All proposed connections 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 January 19', 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 • . rill start Card No. N12564 N ATE S WELL REPORT 1L Water Right Permit No. AAD06S STATE OF pASHINdTDN ._yJ�W.,,,�� Address NZ 6970 ARCADIA ROAD illtI N, NA 96564- ._ S 1) OWNER: Name mimic, TZ1ZY • ^ - 11 1/4 1N 1/4 Uec 30 T 20 N. R 2N WM Lai l2) LOCATION OF WELL: County maws �d/ (2a) STREET ADDRESS OF WELL (or nearest address) 81 6970 ARCADIA ROAD _ li (10) WELL LOG _ (3) PROPOSED USE: DOMESTIC Owner's Number of well Formation: Describe by color, character, size of material (4) TYPE OF WORK: (If1 and structure, and show thickness of aquifers and the kind h more thanone) y 1�ZM�,y Meethod: ROTAARR Y and nature of the material in each stratum penetrated, at least one entry for each change in formation. (5) DIMENSIONS: Diameter of well 6 inches FROM TO Drilled 139 ft. Depth of completed well 139 ft. MATERIAL mows CLAY Z 3 Q 1,1g1116 m11D PAN 3 17.3 C (6) CONSTRUCTION DETAILS: 37.5 40 Q Casing installed: 6 ' Dia. from +2 ft. to 139 11061f BA1D) CLAY a ORAV1L ft. 13 WELDED " Dia. from ft. to ft. =AY CLAY 40 68 R 40 Na.Dia. from ft. to ft. BLURCLAY61 63 01ZAY RAND CLAY 6S 96.5 K'� CLAY 63.5 96.5 Q Per/Orations:of p: fo BRAY CLAY P1k GRAM 102.59 .5106 — SIZE of perforator used in. sAAD GRAY CLAY C SIZE ofp perforations in. b106 115 ft. to ft. BAND i �� ow CLAY 115 124 perforations from ft. PACIND ORAVIL a NiTQ perforations from ft. to 124 139 r perforations from ft. to ft. LOOSE BRAWL NATI, S' Q Screens: NO �., Manufacturer's Name Type Model No. from ft. to ft. slot size f3 Diem.03 Diem. slot size from ft. to ft. .4.r Q Size of gravel Gravel packed: NO ft Gravel placed from ft. to au dd Surface seal: TWA To what depth? 20 ft. Material used in seal 1ZNTOWIT•1 4.+ Did any strata contain unusable water? NO ft. C Type of water? Depth of strata 03 Method of sealing strata off I.. L. 03 (7) PUMP: Manufacturer's Name H.P. Type (6) WATER LEVELS: Lend-surface elevation Z above mean sea level ... ft. Static level 119 ft. below top of well Date 07/23/93 (A Artesian Pressure lbs. per square inch Date 8 Artesian water controlled by pork started 07/22/93 Completed 07/23/93 (9) WELL TESTS: Drawdown is amount water level is lowered below WELL CON.STRUcToR CERTIFICATION: I constructed and/or accept responsibility for con- CD static level. etruction of this well. and its compliance with all Q Was a Pump test made? i If yes, by whom?down after hrs. Washington well construction standards. Materials used OYield: gal./min with ft. draw and the information reported above are true to my beat V knowledge and belief. UU 44— Recovery data �� DRILLING print) Q Time Water Level Time Water Level Time Water Level NAKS INC. (Person, firm, or corporation) (Type C ADDRESS 81 17 WAL Date of test / / hra. (SIGNED) License No. 2053 Bailer test gal/min. ft. drawdown after ra R Air test 15 gal/min. w/ stem set at 133 ft. fMorer l Contractor's Qa Temperature flow of water 6Z Date 07/23/93 Q, Artesiang p'm' Was a chemical analysis made? MO Registration No. ANCADDI091 0 5380 SE ARCADIA RD Parcel 220303190030 WEL2023-00008 From applicant Josh C.on 1/8/2024: "Please find attached photos showing a capacity test that I believe meets the second** condition." ** 2)A capacity test within a 24-hour period that produces a minimum of 1,600 gallons. i�ltONS 1y _ `.� �,3OD n, es Mor tar 0/1tf .. Ga110N5 'i 2" i ` AA Metesj 60 i~66-611a - ro T MO/ter `'� V Maier 60 / 1 ar ____ Vet-on ..vwt Monday January a 5:398:25 41,959,300 gal-41,957,600 gal = 1700 gal total 1-4 N N N N 1-4 ►-4 1-4 F-' ►-4 N N N N N N )' NJ NJ NJ NJ N N.) N N N NJ NJ ▪ \ \ \ i V V V V V V V V V V v rro =.4) Iv NJ NJ NJ NJ NJ NJ NJ NJ N N NJ• NJ NJN N (p . 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S L-1.7 Specific location or address where sample collected: Special instructions or comments: S 31'0 S1�l oo•11 t,t Q1S7(/ Type of Sample(must check only one box of#1 through#4 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 Chlorine Residual:Total Free ❑E.coli-GWR(A/P) ❑Fecal-Surface,GWI,springs(numerat,on) Unsatisfactory routine lab number: Filtered:Yes No - ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other / / S 4ASample Collected for Information Only Investigative Construction/RepairVC Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present andjSatisfactory ❑E.coli present ❑E.coli absent �o`oliform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC 0 Bacterial Density Results:Total Coliform _/100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code4fcM9223B ESM 9222D Date and Time Received:t a Z6 ❑SM J9215E ❑Enterolert3 6 \l 2 L Date and Time Analyzed:4•)y. Date Reported:(011 2'L Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 3 .3 DOH Form b331-319(revised 01116) -- - ^ �� 2194681 MASON CO WA 03/0912023 10:38 AM NOTCE Mint I IHRCHER I IIII II I11111111 IIIIII 1 111 I11111 111111111E 111111119e s: 2 Return To V.cLL V .--3.r se- k:,-c :, Y -A r C,��l Grantor(s): (1) ke (� c er , (2) 'rot rl''ta .A 3 .aCi Grantee(s): (1) PUBLIC �1 �� --1 n Legal Description (1)-1-9) 3 ,Y �X�� ZO-120 R 2 bhreviated form: i.e. lot, block, plat or seecction, township, range) Assessor's Tax Parcel: (1)1 2_ 0 3 D -T \ - 0 0 3 -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) Z Z U 3 O - 3 I - ciD030 Tax Parcel: (Connection 2)1— 2_ 0 3 0 - 3 1 - goo `n) The system owner is responsible for keeping this system in compliance. The name of the water system is: NA U Ot. 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. 74/144_ , 2a1� Dated on this 3 day of Signature of Grantor(s):� � (1) S /13�tei , (2) CIiC�I • ` Page 1 of 2 !.1111.11.1.11711111.11111111111.11111111111111111.11mmlallill M State of Washington ) County of Mason ) I, the undersigned, a otary Publi in and for the above named County and State, do hereby cerj'fy that on this day of ri_a l , 2 0 zj1G�fliak/I -j'?I�'fY personally appeared befor; 1 e, who is known to be signer of the above instrument, and acknowledged that he (sh:ati signed it. GIVEN under my hand and official seal the day and ear last above written. ``�,p sg on F L/�'% Not. Publics in and fo he State of ashii gt� , :`-J:F`•\5-20.. 4%:.cS' residing at C1v z IO -rate-at/a( )1 �L, .)1- 0)1 N S a • :0 0IARy N': ' My commission expires: t,(//, o u \G v. 2 V9jse.!umbes " ���• '/iiF OF�W AS \�`�\ Page 2 of 2 r , . / . • s . • 47 RIM , , PROMISE)amimc 00/APONENTS . ®Mix STUROUr Kum 0 WPM frusour IOARAOP 0 r ®AERATION SEPTIC TANK 1 nor en efe : .0 RAP TANK ? 7 ®sumc Tower=Lea 'I/ /.//sm c C /i// 4,*,ec coma Box ////// ""Alt MAIM DOWN Ran /./.. /./..r. 4r47, 0 MONITORRIOCILEMOUT PORT(TYP.) ® I I 49 °owai RBA RUMS AREA : At 120' / X 0 1 ,kti .1 . . SCAM 1..40' .1 • tAS4) 1110 %. iwrwros .1. 47 ea es .1..1 .1. 1 '1. 44.ce% .1 ' 41beig, .1 i 1, 1. 1 .1. ‘,.-----(4) .1111111110 .‘ \ \ . 110. ,. •`..,,,, ,••-` • revery,i • ,.. ,. .•. 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