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HomeMy WebLinkAboutWEL2023-00059 - WEL Application, Design, Letter - 10/26/2023 584 MASON COUNTY 415N 6THELTON: SHELT967 ,EXT 400 ' ` THELTON:STREET,SHEL ON,V EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX. 360-427-7787 Desiree Gilchrest 1670 NE Old Belfair Hwy BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00059 1670 NE OLD BELFAIR HWY 123174300090 The 2-party water system, SIXTOE (123174300090/123174300090), 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 i • CC• t72023 MASON COUNTY. cE+VEO Dateceiveg a COMMUNITY SERVIC 'co...ski Building,Plnnnsry[r ,n menm Health Lemmun n Health 413 N 6e SnceL(Bldg 8)—Shelton.WA 98584 WEL X626 y 6l6 / LM Shelton' 36(W27-96705400 Bclfair 360895-4467V00 EIma:360-082-5269 5400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION HONE APPLICANT /? 6'iteHlaisT(� I 1 '/ , 36.o go/ cae7 M/ 7R�_STREET,cI/STATE,ZIP ZIP 666C-A, C.. AI-cJ f Y✓G LP-4/R. 44. 9ReA SITE ADDRESS-STREET.CITY.STATE,ZIP J'An14 6 PRIMARY PARCEL NURSER(WELL SITE) /Z23 /7yy3/�Y 9Y.0 SE�NDAR2 PAIRC,N M rAUPLIOAE1910 WATER S/RCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 3 LOT SQQE 0 New�Existingg Well 0Spring /. Cc? ZrQCJ PROPOSED WATER SYSTEM NAME(REQUIRED; CJ \f/X77 PROJECT DESCRIPTION DIRECTIONS TO SITE)CONDRIoNS Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,\driveways,roads.septic/sewer components and lines,easements.etc...) ,- `y w PcG r[ J Submittals Checklist: (these additional items will be required for approval) I4 Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) ftWell 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) Septic Records (additional locating requirements may apply if there is a lack of septic records on file) form may be scanned and available far public view on the Mason County Web site. Revised: 10/13/2021 Page 1 of 2 Sti' :! :JS: if lk Review Step 1: Well Site Inspection:' muse- 73f+ flu^ YES NO NA 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 foot radius of the water source? If so, is road private, County or State. What is distance to ROW? IN ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) X �❑A ❑ Is the well cap satisfactory? ❑ Nl ❑ Screened and vented? pp 11 ❑ The well casing extends 7.S above level ground/concrete slab? (circle one) 4 ] ❑ ❑ Is there evidence of a surface seal? (af: 4j W 67356 W ❑ ❑ Does the seal appear adequate? LO/I: -2Z- g2g4635 ❑ y ❑ Is a variance necessary for well site approval? Comments Mf Pass ❑ Fail Inspector Date ' I /$rzf Z/ _. Review Step 2: Two-Party Review: • trot (LG : Fr641c OM 41) Oil I Z(6/f s /O6E/-I S NO NA 1/ 1 ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 5//0/Zo z3 Driller Mt vl0fra Rol GPM "-JO( Y f Li ❑ Received Satisfactory Bacteriological Analysis? Date of test 3//f/ZS [)r ❑ ❑ Received Signed. Notarized, and Recorded Notice? AFN 22038197 X1 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments itrApproved [] Denied Reviewer Date 1 tlly1T-oL _ Pindlnps in rhts iLsiess reflect obsessed candubous as Phis CTINtecl on the dap of the sae tnspeetion d'o chum it made .cprred r inpp/iLJ of the now ss xnroest I»failure uftlria rr stem. II ell,sire approval Joe. nor.mrnsrih0e IL cacr ty'stew ap/ or n/. II soot csmnn apprmill is a rub-poi process Ill p.-pnc CI e r mtur nu[n!IC 0 eib era Will r to varrr Lkiett11110I eclat,emend N rimi Of building per per I/('<'66S Lliciro wogs,ibttsztLens and sisblopmal Rrc r 01rph se ail I. drllld!utter Janumi l9". 201,S per GSS4R 609/. Revised: IC'I i_^^02_I This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 File Original and First Copy with Department of Ecology WATER WELL REPORT Application No. .. . .. . . Seeond FMB'-Owner's CoPY Third Copy--Dftliers Copy STATE OF WASHINGTON Permit No (1) owbrEB: Nettie . A.V. Neuchatel Addr s Star .Routo.2E_Rox 782, Se...... Wash. es as Iw (2) LOCATION OF WELL: County Milan 0 CL Beating and distance from section or subdivision corner 41 C (3) PROPOSED USE: Darnall° CIE Industrial Et IdwiltiPal D (10) WELL LOG: Irrigation Li Test Well D other 0 Formation:Demnbe by color,character, Pie of mote-Kat and strut-We,and : • °weer. number of well •Mto thieknem of aquifer*and the kind end'dew'of the material'In each (4) TYPE OF WORK Aralfill penetrated. with at Bast one entry for each mange of formation. VI Ill more than one).- MATERIAL . FROM TO ...E New well [IF Method: Dug CI Bored CI 0 10 Deepened 0 Cable 0 Driven 0 Gray Rim swirl 8. rlay C Reconditioned 0 Rotary 0 Bitted 0 Brown clay 8. gravel 10 25 O water bearing gray brown muddy c (a) DIMENSIONS: Diameter of well ...6 Inch... sand 25 31 O Drilled 3717 ft. Depth of completed well 3717 ct. • 47.1 Water bearing Gray browintatAs tO (6) CONSTRUCTION DETAILS: than 3]. 35, . E Water bearing gravel _35 37'71, Casi ng installed: 6 - pica from ... . .... It, to _ z__it. 0 r- Threaded ID " Diem from .. ... It to It C Welded to rt. .2 Perforations: Yea 0 Na 05 4.1 -- Type of perforator used So SIZE of perfOrationa in. by in. ;3 perforations from ft. to . ft. . -. C Perforations from It. to ft. F3 Bodoni:lone from . CR a-. Screens: yes 0 No a ea O Manufacturer's Name - Type Model No... ..._.... 0.1 .0 Dian. .... Slot .Ise from ft b St. -- as Slot dm . from ft. to ft. YR FiT iz ill >, -------, --- --- = Gravel packed: yes 0 Nirly2 Size of Breve;_.. fff Gravel placed Dom - n.to . n. 1- - ; :-C, 1 ji 1.(j75 N— - (Is Suilace seal: yes Or No a To what depth/ ._..__Ls _ rt. Material used In 3tal....Bent•ni.te. DENALIENT OT .'7."A_Jii - Did any strata contain unusable water, Yes ID No 0 — O Type Of waterl- ..... Depth of strata. JCE Z Method of seallim strata off VI ty (7) ?UAW: manufacturers ruune.„...Att41.4....int.. . O Type: - HP ---- — BA (8) WATER LEVELS: alnde-trree„ealeigzo. Of 12 ft. below top of well Datt../2/6 0 Static level _ ID Artesian pressure . it.. per square Inch Dale. . _ LI Art Ian water Is controlled by IL (Cep,valve, etc.) _ 4 (9) WELL TESTS: oraw n dow is am il -- amount water level l lowered below stac level 6 ti _. Work started 11/22.. 19-25. Completed.... .12/4.. ........ lil :15 as Was a pump test made Yea lit No D If yes, by whom?... OWTHIN. ., C Yield: 10 sm-untn.with 4 ft. drawdovm after 1 hrs. WELL DRILLER'S STATEMENT: CU E . Thla well was drilled under my Jurisdiction and this report is •• - .• - true to the best of my knowledge and belief. s- _ 43 Recovery data Dime taken aa zero when pump hinted off) I water level 0. measured from well top to inter level) NAME Frankia Dr ill ing 0.1 Time Water Level Time water Levet Time Water Leval a (Peraon. firrn. or corporation) (Type or Prim) 0.1 Moress....Einde...b....E.X..2084...Par.t...0r.cha...r.d.....Wash .c 1 . „ ....... I- sate ot test . 12205. (Signed] Crec-272::2gessa. -wresatde.l- Bailer left MIJMin. wItb ft.drawdown after hrs. Well Denier) Temperature of water.. Was•chemical analysis made?Ye•CI No D License No (2_2,s-cv Date...4fra.............. , I9.7C LUST ADDITIONAL SHEETS TY NECESSARY) S.F.No.ll16-OS-(Rev.4411. 0 NICHOLSON DRILLING INC. PUMP TEST NAME: Qe,2 I� DATE: 08//0/Z SITE ADDRESS: //p70 A/F XL/ L /)' Hwy I�Q tL�,9 2 9 2 WELL DEPTH: PUMP WATER CONE PUMP DATE TIME TIME DEPT TEST RATE GPM REMARKS 0 0 6 13 6 1 .15 � 2 ZS. 3 31 .3 13 6 4 -51- 2, 11 Sec 5 33.4 1 Z.7 6 33 'b,-1 7 33. L1 8 31 .9 0 9 10,6 10 ''0.6 11 z9.1 12 29 .0 13 TS. -9- 7- S It O SeCC, 14 15 20 t' pef4,4ot4 b y 25 `]ecy,z) .aa+ ?c, 30 35 _ Licence 43 SST 40 45 50 60 70 80 90 100 120 RECOVERY DATE: / hOi 40 WELL DEPTH: WELL DIAM: PUMP MAKE: N% PUMP MODEL: N�I/} TANK MAKE: TANK MODEL: W2( cS 5 ELAPSED WATER ELAPSED WATER DATE TIME. TIME DEPTH TIME DEPTH REMARKS 1 Z3.6 50 2 ZZ s 60 3 2 t 70 4 19 `o 80 5 lq 90 6 Lg6 100 Z'U'4 7 120 8 150 9 180 10 210 11 240 12 270 13 300 14 360 15 420 20 480 25 540 30 600 35 660 40 720 45 780 Date: /C��z'r ' Customer: 5/ �F .5 62JLi',-, NIS i Address: /7, 7/7 WE ice:4 e� C/-4/JF A.) K S/ J F/ fA J/2 i4 /A `1i�rze I Water System Data I. HORSEPOWER: \I V PUMP: • or Jet —CYO 2. VOLTAGE: j -/�v AMPERA 0 . 3. TANK (Gallons) : IC i '— t TANK PRECHARGE: PSI 4. TANK TYPE: or Gala TANK TANK CHARGED TO: PSI V� 5. DRAW DOWN; OD POINTS: 9/ OD a_ 6. PRESSURE: 1._,, to DROP PIPE: V. WELL: Pitless or FREEZE PROTECTED: �� WELL SIZE: b' inch OUTLET: Well Height: _ \ BOOSTER: Volts Surface Sea or No Booster HP: PLUMBING: Oil al Poly Copper Pox Model: DISCONNECT: ox Na AMPS: Disconnect /� f� 1 r/ ^\ . Type: L//< ` POORHOUSE: Fair Bad Reservoir: Static: (8 MEG READINGS: l R-C t V-G Depth: 4 00 ( OHM READINGS: (�.q is-v 218 a-u '(J]. to-r Pump Set: 3-4 GPM Shared Well WELL TAG/0#: Comments: Suggestianr JI SPECTRA Laboratories-Kitsap - h (57 I �d ...Wham amarn...mane., )U/ '1U ell V COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected I Time Semple Ccuny os i to l tip, Collected .00.ge Mo.SOP y' Type of Water System(check only one box) ❑Group A ❑Group Group A and Group B Systems-Provide from Water Facilities Inven (Wily I -c sin 1c °� 3 D e s i ree X. I e r;5 t System Name: Contact Person:Nicholson Drilling Day Phone'(360)8764421 Cell Phone Emak: ` Eve.Phone. Semi results to:wMt lea non..adds.and*ode or emm am tor siecimele yevy of roubl hivittmon ornimo no Box Iva Pm orUera WA 98366 office.nlcholsondrilling©gmall.com SAMPLE INFORMATION Sample collected by(name) Vt ' e0\ — Specific location where sample colle cted ted Va Special instructions or comments. Type of Sample(clerk only one box) 1.❑Routine Distribution Sample(AP) 2.❑ Repeat Semple(AP) Chlorinated:Yes 0 No (from disbiWtion system enemata routine) Unsatisfactory routine lab number Chlorine Residual:Trial Free 3.Ground Water Rule Source Sample Unsatisfactory fine coneddata: B I ory rou Chlorinated Yes No ❑Triggered(AIP) Chlorine Residual'Total Free ❑Assessment(PR) • 4 Surfaces I Raw Source Water Sample(Enumeration) S I ❑ OF ❑Foal nkred Yes_No 5. Sample CWltthe for l51°Miami Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total CW6orm Present and 9gatistactory ❑EuoIi present ❑EtoXabsent / Bacterial Density Results:Total Coliform pN100ml.Eno/ mprii OOml. Fecal Cddorm clullCCml. Replacement Sample Required: 0 TNTC 0 Sample too a4 ❑ Sample Volume ❑Damaged Container 0 ry� Lab Reterence Number 111�3 II ZS 7,3014/r 'O RecepI Temp C NWIhoECode'. pN929Sl OT NT/SM9222D Cate Reported „otomet II and Ne.CM" matt. siardner ua AUG 12 2023 _::rd clout : ,�,.a•e avygyvnymiymen DOH LabSamgee om. G64'0( Dar con wuwlnaMNrol I -S -e F Y Y w t a "y 3 ally 3K g s1 Ek gg e AFa ti $ $s1 a s s 3`3 e$° § £e � ; a1€4.4 ,a 1 isY a ° .! a s°gc [(e) �5m . . z¢.z& zzr3� E Y E u maEE„9 a �9 g lgi38 4 E6' � pa 5e o m € • 0 l:2;"15 .3z $F's€ 0 � waJg aa S € '' �a°ta _ . , € aga&Eai$HPAg-- ; S a €9aaas a 3 �s a' 16 .� "$ s is p7§4. gigwOli9 a39 h a �w® I kg 2 e'1;3 ':a 53 0s dad 0:' .A ;< k s 8wa = r a3 � sa sr / H a t ° 'h o = gas i>jgls �azz p 1 — i es ° s8Ra §§ M c= e ° o #k @ al IHI: n i e�' qC2- 'a - k a F I' a5y'y re 21 o y 9P I 1E I �Ii+ I 83 �s Ogg° I o I dPeV_ 3\°, \�n aEa 4 ra -w � �5 0 PC 8 -1 s.o u S e� "ryaa\ °GC I 1 eac 11e Sm gm Y°o— i