HomeMy WebLinkAboutWEL2023-00055 - WEL Application, Design, Letter - 10/10/2023 _,..7 .
ASHELA'S O N COUNTY 415 N 6TH STREET,SHELTON,WA 98584
TON:360-427-9679670,EXT 400
{{{1 BELFAIR:360-275-4467,EXT 400
-f Pu 'Iluc ealth & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
FRY JEFFERY I & L TTIE M
PO BOX 1541
SHELTON, WA )85E (I
1
RE: WA ER YSTEM PERMIT: TWO-PARTY
WEI Q02 -00055
91 ' Wi ver Creek Ln
421 p2;1 0033
The 2-party wat sy I em, 2-Party Private Water System (421192390033/421192390033), has been
reviewed and is ere y APPROVED for 2 connections. Please continue to follow best management
practices with m intE ing your water system including regular water analysis, landscaping, keeping
wellhead area fr:e o contaminants, and stormwater management around the water source.
If you have any we: ions, please contact me at 360-427-9670 Ext.353 or email at
danderson@ma pm untywa.gov
Sincerely,
David Anderso
Environmental l- .aIt Specialist
Mason County E Tvir nmental Health
i
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OCTJ
?0"�4v:. P1t. Date Received: '-
,, MA OUNTY 0 - t 0 - 2RF�Fi ?3•I I, 1Amou trRQ ed: Rec v 8 ��,►COM - TY SERVICES ��S. I ���
z .,, Building,Planning,Environmental Health,Community Health
Ivt. ,�a 9�
��,l.. . G D.-r2
415 N.6'h Street,(Bldg 8)—Shelton,WA 98584 WEL . OGOS
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
1 PHONE `
APPLICANT rc Le 3(Z0 -.2oc - $
MAILING A ' p GR,oxEET,/CITY,5STATE,ZIP c k ay. 'pt 5 B-s V
SITE AD DRESS-STREET,CITY,STATE,ZIP ' � � �� ��� 7/���(,l/
y/ 0 We«u- ...r' C �r k ►-, She Q
PRIMARY PARCEL NUMBER(WELL SITE)
9 2I15 - 23 - `i0033
SECONDARY PARCEL NUMBER(IF APPLICABLE)
TQ Z Y 00 33
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New IS Existing IS) Well ❑ Spring 2,2/4c.Nrs
PROPOSED WATER SYSTEM NAME(REQUIRED)
.2.. porgy pi;v, wr~ r Sysk-.-.
PROJECT DESCRI�ION
IM I(er,,,IA 4ke ii.ni Mow`,. h u,N,k -t- Sy,-.:, -tom /(It LA Ad.tL Iti,,,:LA ' lf\w.,.t...
DIRECTIONS TO SITE CONDITIONS `-
Al. /e l +0 tALJ le-AA P i f4�c V r y c, �c E€ I 1 S k s. t, l<u 20 Gt vvw 4YJ C /1 4 Kt a 4
1-..•4%" i2,s ht c.),A PeA.1..., " C:e k LK at-' k.t.. &v lti i
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc...)
IfF. MIOWT -
OCT 1 0 2023
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)
4 Notice 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: 10/13/2021
Page 1 of 2
Staff Use Only
.-Skd► L6` a Paa + Ci►f a 04 C 'i ca15.
Review Step 1: Well Site Inspection 35.
YES NO NA 11/10C/74.
O ❑ ❑ 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 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
1 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented?
❑ The well casing extends above level ground / concrete slab? (circle one)
[X1 ❑ ❑ Is there evidence of a surface seal? i, : ZI‘Q M
tg ❑ ❑ Does the seal appear adequate? (OV ' —(23,2LtS 4rSf
❑ tyi ❑ Is a variance necessary for well site approval? U : 6 ()--2-
Comments i Gv¢ o.[• y well (op mfr1if bol /s foocc - C 1 /( /67zoz3
Pass ❑ Fail InspectorO----- Date / //2/ ?O?J
,
Review Step 2: Two-Party Review:
YES NO NA
pr ❑ ❑ Water Well Report with adequate pump test on file? //
If NO, date of Capacity Test 6(6l1011 Driller k?yf Of/l fri GPM 25
j ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 3�ZZp1UZ3
9 Li [1] Received Signed, Notarized, and Recorded Notice? AFN 22O-1 2 Z 7
g- ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments 1 Sa o- contoinek4kv, Cofitcled `f/ how.evee/: 11/6(2azi
Approved ❑ Denied Reviewer Date il Via? .
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'h, 2018 per ESSB 6091.
I
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
•
WTER WELL REPORT CURRENT
A 1•only-lealecy,2"copy-owner,3"cuff-Mike Notice of Intent No.yY 300039
e.?Of
EECOLdGrY Construction/Decommission('x"in circle) Unique Ecology Well ID Tag No.)}AR 122
f OnS ruction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION ply Owner Name Jeff Fry
Notice of Intent Number
PROPOSED USE: ® Domestic 0 Industrial 0 Municipal Well Street Address n Weaver Creek l.n
❑ Dew.ter ❑ irrinetiaa 0 Tea Well ❑ Other City Shelton County MOW
TYPE OF WORK: Owner's number dwell(if more than ooe) Location �1/4-1/4 (�1/4 SOC]$ TwA Z11I R ttwaa ❑
21 New swill0 Deepened ❑ xaeonditiaoed Method Ei C ?
Caable D Rotary 0 Dosed Lewd (s,t,r Still REQUIRED)
or
El
weird
DIMZNSIONB: Diamstar of well Q Maim.drillod221 R
Depth c400iipieted well 2$8.
CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Afi.n/Sea
Caen{ ® welded Diem.from ft.to k22 ft. Long Deg Long lvfn/Sec
Installed: 0 Liner instilled • Diam.from ft.to • It. Tax Parcel No.(Require _d$2119 23 900
❑ Threaded ' Diam.From a to ft.
Peresrelleem ❑ Yea ® No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of perimeter coed Remake:Daeortbo by ookor,chmeeter,sine of materiel and aruonne,and the find sod
SIZE of pert in.by in.and oo.of serfs from�ft.to�ft. nature of the material in each shaWm patented,with at lad toe entry for each champ
Seasstae ® Yes ❑No ® K-Par Location�Ql of e. (USE ADDITIONAL SHEETS IF NECESSARY.)
MATERIAL FROM TO
Maobnvuer'e Name alloy Br sand&gravel loam 0 11
Type Model No• br 11 29
Diana.Not its$Q from 21 li to 2a tt br sand&gravel 29 48
Ditaa Slat ace Sun R to ft br sand&gravel
Gremif liar peeked: ❑ Yes ® No Size of gravel/sand ester bearing 48 60
Maori*cad from�—ft.to
Ne se.seek ® Ye. ❑ No To what deperl 18.511.
Material euod in seal bentonite
Did any Welt contain tmusable woe? ❑ Yee ® No
Typo of water? Depth of strata
Method of mein%strata off
PUMPt Manotcerses Name gpUlde
Typo llt) H.P. 1.5
WATER LEVELS: [and-surface elevation above man sea level ft.
Static Wed j1Qe.below top of well Date 5-00-2011
Artesian pereete lbs.per swam inch Date
Artesian watr is coatraaed by (cap,valve,roc.)
WILLTESTM: Dnwdowa is amount wee.,level is lowered below static level
Was a pump set aeade? ❑ Yea lA No If yr,by whom?
Yield: anomie.with_ft drawdown after hrs.
Yield: �aLlmin.with R.drawdown after bra.
Yield: µLimin.with_R drawdowo air bra.
Recovery data(that tato,m taro wheat puny turned of(reran jowl meashowd fires
will top to astir Tree!)
Time Water Level Taw Water Level Time Water Level
Date of lost
Bailer rose IA OalJmin with it drawdown after bre
Antes* ylimin.with stem set at_It for_hrs.
Artesian flow a.p.m. Date 5-05-2011 Start Date 5-2¢2011 Completed Date 6-0-2911
Toupaanae of water Was a ohamial analysis made? ❑ Yea ® No
WELL CONSTRUCTION CERTIFICATION: I constructed and/or aaoept responsibility for construction of this well,end its oamplienoe with all Washington well
000stnuction standards. Materials used and the information repotted above are this to my beat knowledge and belief.
®Driller 0 Engineer U Tninea Name(Price)dale spas Drilling Company KNAPP DRILLING INC.
Driller/Engineer/Trainee Signal Adchass 50 E Lame Dr
Driller or trainee Lioeose No.2921 City,State,Zip Shelton , Wa, 98584
IF TRAINEE:Driler's License No: Ccntractar's
Driller's Signature: f)+.lo C Yt c Registration No. J5NAPPDI952B1 _ Date 6-09-2011
t ' • Q 5Q 1 4Rp��vL,02/l ( ltot me dp s i� a •? cal!the Water Resosrces Programor at 360-407.6872.
. s�4 � wlth htaiiiiti eiaCaf71d for' faihb8ton Relay.Servla. Pcrso+ with a speech dfsab/dy can ca11877-833-63!!.
::ri,ttt"d County Mg:-
Thurston County Environmental Health
- ' ` 2000 Lakeridge Dr.SW t Olympia,WA 98502
...
360 867-2631
rttuRslx)N couvrv.
gnmscomaKau
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
5 '2,2' ,23v � a s"ri
t1on:h Day Year
Type of Water System(check only one box) 004Kvate Household ,`�
❑Group A 0 Group B "'Other�ll�/LA [
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name.
Contact Person: ‘Te cr.c el, Fr
Day Phone:( `` ) ✓1 Cell Phone:�)Z0�.9
E-mail:J� +tir c.211 eibe+ma.:1 ,G.btvv Eve.Phone:( )
Send res Is :It rint lull Caine,address and zip code or email adze )
Jam.c_r_e __Fr l_.___ d r3Ci..4 lie AO roll Yn
P... . --1 - 1
S1n ,-, �.._ 5 .._. _._.—__ _ ____
SAMPLE INFORMATION
Sample collected by(name): ) c ,1,_I e_ I r
Specific location or address where sample collected: Special instructions or comments:
q I iv. leaver CreeK 16frt
SI>.t'fvn, via . 9 g5f1y
Type of Sample(must check only one box of#1 through#4 listed below)
1.C rcoutine 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(AP)
Cl Fecal-Surface,GM.spnngs(nurneraiion) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S
4.0 Sample Collected for Information Only
Investigative Construction/Repairs _ Other_
LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY n
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent o oliform detected
Replacement Sample Required: t)
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Colifonn /100m1. E.coli 1100ml.
Fecal Coliform /100m1 Enterococci _ /100 ml.
Method Code:IA
SM 9223E ❑SM 9222D Date and Time Received 1✓DL
SM 9215B ❑Enterolert® --DD- .3 City
Date and Time Analyzed: w3` a3 Date Reported )3(4
Sample Number(DOH nurn5er pin the dgite) Lab Use Only.
0 8 0 146 -1"
DOH Fomr 4331319(reused 011161