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HomeMy WebLinkAboutWEL2023-00053 - WEL Application, Design, Letter - 10/11/2023 MASON COUNTY 415 N 6TH STREET SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 - Public Health & Human Services ELMA:360-482-5269, EXT 400 FAX:360-427-7787 CHAMBERLAIN CHRISTOPHER & SHELLY 2301 CAPITOL WAY S #3 OLYMPIA, WA 98501 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00053 307 E Capital Prairie Rd 320084390021 The 2-party water system, Chamberlain Well (320084390021/320084390021), 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 Sin/c�erely, ! l David Anderson Environmental Health Specialist Mason County Environmental Health 400 0cr MASON COUNTY 427 HI- 5 COMMUNITY SERVICES By �(�� � ova U nvFmm IACommw.h Health Re e.aa e f 0 itsN Street,(Bldg 2Shelton,WA9S584WEL 2(72.3 (.)C !Mellon ](f 12]-961U xJW Belfair 360-2754467 x400 Lma:360182-5264 .e91H1 I< TWO-PARTY PRIVATE WATER SYSTEM APPLICATION AC IA.?APPLICANT C4 s..WLbu—la;h PHONE Co)3c 4( s( - 386.0 MAILING ADDRESS-STREET.CITY.STATE,ZIP zfol aid-o( Lt4,� s �f3 vlyy wa 4ssot SITE ADDRESS-STREE__i TCITY.STAR, IP G R^E 3b7 , eet slPra:r:- tot S4.Afe.A, tar °l%S(s`l PRIMARY PARCEL NUM 3aoo4 - H3 "total SECONDARY PARCEL NUMBER IIF APPLICABLE) .3aoog —y3 - 9oDtI WATER CE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE 0 Nev jExisting ®-Well ❑ Spring 1. 27 PROPOSED WATER SYSTEM NAME(REQUIRED C11MI,44.4rt^ WCAI PROJECT DESCRIPTION 2-P. ly w..(( DIRECTIONS TO SITE CONDITIONS Site Plan: (may also be attached) (property boundaries,structures,well site w1100'radius,driveways,roads,septidsewer components and lines,easements,etc_.) Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) II 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) ep 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: 10113/2021 Page 1 of 2 Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ ix ❑ Evidence of existing sources of contamination within 100 foot radius of water source? ,�-r (drainfelds, tanks, buildings; indicate distance on plot plan) ❑ Dp ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State. ?i / What is distance to ROW? 121 0 ❑ Does the ground slope away from the water source site? (show slope on plot plan) X 0 ❑ Is the well cap satisfactory? 0 0 Screened and vented? ❑ The well casing extends !(7 above level ground I ill7 concrete slab? (circle one) 1,4 ❑ Is there evidence of a surface seal? tat; I Y. 2 3 200 Li Sf 0 0 Does the seal appear adequate? ., — 11 223 .b83o7Q6 /❑ ❑ Is a variance necessary for well site approval? 'r. Br( 036 Comments p�7 7 y } �I Pass ❑ Fail Inspector 1� Date ( 0/2,57LQ(/J Review Step 2: Two-Party Review: YES NO NA 7 ❑ ❑ Water Well Report with adequatete pump p test on file? 0/z V L If NO,date of Capacity Test 08 Driller 1!T cadi(p� D>&gbh GPM 26 0 ❑ Received Satisfactory Bacteriological Analysis? Date of test a12(/2I 3 0 ❑ Received Signed, Notarized, and Recorded Notice? AFN 7 20307 :( ❑ 0 System appears adequate to serve 2 single-family residences based on information provided? Comments Approved 0 Denied Reviewer Date 8' Ol 2U 3 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 W'ater System approval is a two-part process. 4ll proposed connections to new wells are subject to water adequacy requirements at time of building permit per %1('C 6.68 Water usage restrictions and additional fees mov apply to all new wells drilled after January 19'h, 2018 per E.SSB 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 • WATER WELL REPORT ® DEPARTMENT OF - Notice of Intent No. WE53210 ECOLOGY Unique Ecology Well ID Tag No. BPF036 Type ofwox state of washing ton C Cmsm=Hon Site Well Name(if more than one well): ❑ De rM-ono Od%noaGomlleu®NOI No_ Water fight Permit/Certificate No._ Proposed Use OO Domestic D IMmtrial ❑Mmivipal Property Owner Name Chris Chamberlain ❑D`"" 0 Dr'gati°° ❑Test WcO C Other Well Street Address 307 E Capital Prairie Rd. Corot ac on Type: Method' CityShelton County Mason O New well ❑Akerson 0Diiven ❑acted 0Cabe Tool C Dc.eni„g 0 Other ❑Dos I]Air- ❑Mud-R°my Tax Parcel No. 32008-43-90021 Dimensions:Diameter of boring 6 is,to 142 @ Was a variance approved for this well? O Yes Ea No Depth of completed welt 142 fl Construction Details: Wall If yes,what was the variance for? Casing Line:Diameter From To 1lickness Steel PVC Welded Thread iN I ❑ 6 MO 139 025 MEIE 1 I ❑ Location(see instructions on page 2): a WWM or❑EWM ❑ I ❑ m ❑ I ❑ ❑ I ❑ SW #`%ofthe SE Z;Section 8 Township 20N Range 3W ❑ I ❑ m ❑ I ❑ DIC❑ I ❑ m ❑ I ❑ DID - Inlitude(Example:47.12345) 47.231953 — Longitude(Example:-120.12345) -123.085869 Teri/madam: IE Yes ❑No Type of perforator used Air Driller's On/Constitution er Decommission ProcedureNo.or tedfrpetfo sons 96 Size o'peEmaurm+ t/< mby l-tl4u Fomutioo Dombe by color,cbvwq size of material and seveme+audthe kind and Perforated from 118 ft,to 124 Etbelow ground smGu nature of the material in.each layer pens+s{with at least one entry for each change of Screams: ❑Yes El No ❑K-Pack[ b Depth ft information Use additional sheets ifnecessmy. Manv4rnner'sName . Materiel From To Type Model No. Brown Silly loam 0 4 Diameter Slot size is from @m fl Diameter Slot size tofrom eto_e Brown silty sand and gravel 4 32 Brown sand and gravel with clay binder 32 47 samrvume pack o Yes I]No Size of pack material in. Brown medium sand,multicolored gravel,loose 47 61 Mabvi placed from 8to it Multicolored gravel,brown medium to coarse 61 Surface Seal: HI Yes ❑No To what&epth? 18 ft• sand,loose 97 1✓'il poi mseal Bentonite Chips Multicolored gravel,broom coarse sand, 97 Did any Wax comm:mi nable water? ❑Yes IJ No116 Type of watch Depth of sham loose,wet Method of staling strata off Multicolored gravel,broom coarse sand, 116 loose.water 126 Pomp:M,nuamum+s Name Type: Brown silty sand,gravel 126 142 MY.. Pump intake deph @ Designed How rate: gpm Water Levels: Isndxvrfnu eleravon'bore mem sea levet 305 fl I Sock-tip of tog of we➢gig 1 ft_above gourd Sur ere stave wan level 87 @ below top of well easing Date 8/2823 Aneeim pieenvc lbs.per sun inch Date Artesian wan is cotolled by (cap,vane.PA) Well Testy Was a pumping test pe6®ed? ENo ❑Yea O by whom' • Yield gpm with ft drawdmw titer hrs. Yield gpm will ' ft dawdown Mkt M. Yield ppm with_ft drawdown after hrs. Recovery data(time zeroPater who:pump is vaned level measured from well : top to wan level) ' Time Wen=Level Time War=Level Time Water Level ' Due of pumping test Bailer ten_gpm with fr dtawdowa afro_hrs. !.5 test ®a 20 gpm wihst 135 @lbr 1 ens. 1 Date 8128/23 a cm Eva_gpm J Tempaatre.of water 50 •F Was a chemicel analysis made' C Yes ©No Start Date 8/25/23 Completed Date 8/25/23 WELL CONSTRUCTION CERTIFICATION: I couslruMM and/or accept responsibility for consouction of this well and its comphancewhh all Washington well cons'mation standards.Materials used and the information reported above are true to my best knowledge and belief Driller❑Trainee❑PE-PrintNaa9e Josh Koepp Drilling Company Arcadia Drilling Inc. sipvnne :"1- B /. .Address PO Box 1]90 License No.2674 CrI / / � City,Sae,Zip Shelton,WA 99584 IF TRAINal Sponsors LicersseNo. Canaa_-tor's Sponsor's Signmre Reginration No,ARCADDi098K1 Date 825/23 ECY 050-1-20(Rev 09/18) If yaw need this dacwneat in an alrernare format,please call the Water Resosucer Program m 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech dlsabill9+can call 877-833-6341. Vanguard Laboratory I 2635 Parkmont Lane SW,Suite A Olympia WA 98502 2 p}, VMWEDFD 360-967-7010 V�,)()Sb(7) ). COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected m ®am MASON 08/30I2023 , Mumory Her D eM Type of Water System(check only one box) ❑GroupA ❑Group B O Other Group A and Group B Systems-Provide from Water Fadliles Inventory(WFI): IDp System Name: CHRIS CHAMBERLAIN Contact Person:Arcadia Drilling.Inc Day Phone.(360 )426-3395 Cell Phone: ) Email: Eve.Phone:( ) Send results to:(Phnl full name,amass am zip code or email andawudreMme own AND sue@aaemednllmpmm SAMPLE INFORMATION Sample mlected by(name):SETH Specific location where sample cellecled Special instructions or commend #BPF035 307 E Capital Prairie Rd.Snetton Type of Semple(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2.❑ Repeat Sample(AIP) CM1lonrated Yes No (Imn dismwron Spiel"any unsat routine) Unsabsfactay roans lab number. Chlorine Residual:Total Free l.Gmuntl Water Rule Source Sample Unsatisfactory routine cdlect date: ISI I Chlorinated.Yes No ❑Triggered(MP) Chine Residual:Total_Free_ ❑Assessment (AP) 4 Surface or GWI Raw Souse Water Sample(Enumeration) S ❑E cut ❑Feaa was Yea_w 5.Q Somge Careered b Inrorm'mon 0nyi LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Conform Present and W Satisfactory ❑E cob present ❑E.co4 absent Bacterial Density Results:Thal Colilorm I100m1. Ecdh /100ml. Fecal Cdifom I100m1. HPC I1 ml. Replacement Sample Required: ❑TNTG ❑Sample too rid ❑ Sample Vohme 0 Damaged Container ❑ Lab Reference Number D"e'mfgo 7i3 L02c 1t30%SO-12— ReteipiTem,C.: SM92Z36 Dale Reported to DOH Lab Use Oct DOH tab-Samplk 285- 2203076 MASON CO N . CCHRIS1 CHAMBERLAINRM0191601 Rao Far 2O<.00 Pap• 2 Return To ��m11111mmllmm11uiimtmi111111h iil CIA Cp rfr,0 0140r401*-:... ',Z3o1 GpL.I Gkyy. #3 RF�F/tFo ) OIYa.e,o- 4fit 145e1 6 :, Grantor(s): (1) (i&a-vS (%hca,hw16-:^ . (2) Grantee(s): (1) PUBLIC Legal Description (1) (IQ.2 -A of to1,4- it j R 1 e4 SP tt V)'i (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 3 O Q 4 - a1 3 - q 0 0 2 1 solr -t2043 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 a O o 1 - H 3 - cl D D 2 ( Tax Parcel: (Connection 2) 3 a 0 0 1-L 3 - tt O o 2- The system owner is responsible for keeping this system in compliance. The name of the water system is: e.d..L.:., (4..1( 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 6�`` day of CX,664-.- , 20 Z3. Sign/at//�/5/e o`f Graanto/r(s): iThels A__ Page 1 of 2 State of Washington ) County of Mason ) I, the undersigned�,dNM a Notary Public in d for the above named County and State, do hereby certify that on this D4 - day of (kl2'n>,e C - , 20 'L , 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. ar Notary Public i and or the State ashington, TERESA L WAY residing at SSn, I. Notary Public My commission expires:y �112z)2V State of Washington License Number 135501 My Commission Expires May 15, 2024 Page 2 of 2 / ` \ \ _ 4 � `rn<`o 1-r xxxxxxk i_ ?�Aft Q V_' FII 11-11 I n a20 Fi I rn~ ' S ; 'T w NNE 78 VERIFY „( Y '��i '-I �O rLY 1�CI'�� 34 FT e.SJ, .i .* L } i 7 / yA 'Cllr iw� I E o I 7 ',. Q ii 4i . i �i �41*� / j �o P Ad m PS FTC iaio I// Wm w.u� ( C9 03 Z i iiyy ■ it ► r ( w*w \ so'..,_ I�;yi���{I Ip ii 4�.. ,4`Ito Iiy r N 03 � I /Q� � '. 'SLY � l/LC' Aa 1 n 14 a I m 1 6z�i I FQ� I /� i_t � x3c'x xKxuxxx xz - j @ • - a I 4,r7, yrn 0nx x yo0 N " c ea) A� zrZi Q m rn N w .. 20 o N goy �. I wO O Z co V ( o i IGl O r" y n4 > z ID . o .23 � I oNAm N J 51El - � R D w rn 70 = ^' --I 12n rnK j p m p I N ? J nc, cri rn z I n O =i 7, O z 1 D I a c co i co I 4 EAST.o2412-4L Pa -LIZ0 ? _._ _.-.—.-_ -'- , \ , ii,„„iii,I 2 -° a 1 If I i�lq r9 I rril DI I III II 9 I li® r 3 ��w, 1 11111;111111111111 1111a wI1! y1 z ze�a �, I `I `ll II �e ['ai f of z 1 'e. � ' 1 ;114r ii 41 41 III 111 1111111: if #1 Ittql 1i�1I II11 it1 1 II I 4 It A D 2 2_ ,S: i Chris and Shelly Chamberlain P 1 g II 307 E Capital Prairie Rd, Shelton WA 98584 o O _ n ° Parcel #32008-43-9002 I d \-- -4,-- �` ,:c., ., i._____ 7.,____;.. i „. 4' 14 0 . s.ric :x\i' c 5 _____:: ir,;' ocf;,, N - { I . A� ci �' �il� an V. r �µ P I' L. -- IN )��� ��� H ; Tj • R �iR Q` j j aC IIII IIIN _ 1 `w' l i � hl dl'� ] (- 1 o'er s I f S T d N 1 QL tw I . yC1 1131 I ; I� 1 cIti, f, I gOy k W -4 I l I If a .-6 sr.± r1V isI L m C �1 P 11p f r g_ "Lt, , '1 d IL ts � v ir - 4. IL I I I £I O0 tiL, 0 s 6k IA � - • 1 Iyf e , ICY aJ �s � 0 EPI 6{ `Li .k J �D av fl r ( rt �1� N°A _( CD ' '�' 01 p v2 r- w < T �I N'. 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