HomeMy WebLinkAboutWEL2023-00049 - WEL Application, Design, Letter - 9/27/2023 A ` 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. 360482-5269, EXT 400
FAX:360-427-7787
El KRISTYN & SON CONST INC
101 SE ROSEWOOD CT
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00049
3770 E Mason Lake Dr W
221055100025
The 2-party water system, Dryer(221055100025/221055100024), 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
T
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MASON COUN 2023 D P Received,
-
COMMUNITY SE SEtvEo nlIte5 is-- �_ Received
Af� Budding PlanningEnvironmentaHealthn n.Environmental Health rmmun Health _ ,-
II ((�` '-I
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Shelton'. 160427-9670 x400 Dei air:1602175�677Dx400 Etme 360QN�-5269 x41N1 WEL U V 5 LJ V —1
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
cLilOSiY.r/ bSG/r/Er,57 % %C - c39- -3 IL( 7
MAILING ADDRESS-STREET,CITY,STATE,ZIP
(01 Sf.. (ECG WC( ') i 1 - SHE( t(,a COA 9esbcr
SITE ADDRESS-STREET.CITY,STATE,ZIP
3710 2 rrys •N Lase pr . IC Cova Ue(--.) Cv1A C 55(1(.
PRIMARY PARCEL NUMBER WELL SITE) T
cQIn •t 5, t Dona.
SECONDARY PARCEL NUMBER OF APPLICABLE)
O i-t Si Ouo
WA ER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE
0 New ❑ Existing ® Well 0 Spring
PROPOSED WATER SYSTEM NAME(REQUIRED)
PROJECT DESCRIPTION Cccs r • UCf t cuJ c, <Jl_LO 5 '
1—IV A •. _s / ,O J- I, I +4 Sc{a I It- /--ce i $.dL
t "�7 7C — X)e.� ..L.cl( w,ts I. tic a 77o inc.,- s•r 34iPt re4sc"-S _c'Or'LL t.:cw
-H 1`feIJr"Pr43 HSJ@ 14 L'f � ItSc'W� L�L?Sca1 LhCA -S i W1 t ( . - (-<s
DIRECTIONS TO SITE CONOrONS
/2.14sc.i/ G/; 61f) N'E//d Jr r/ 4-/- GiuFSi— /117-56>a / /LC 1e(- Cv 5
1 ,('4-iE jAt()'xv 1(e5 4•x -A Cr-Pi- ,c+ tJc.^tiS /—.ae/ c' /_.Zicle—
Site Plan: (may also be attached)
(property boundaries.structures,well site w/100 radius,driveways,roads,septic/sewer components and lines,easements,etc...)
'U ,1;1
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)
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 toms may be scanned and available for public view on the Mason County Web site. Revised: I/I7/2019
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
16' 10 »rod•
YES NO NA
❑ ❑ 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? l6 -fort £ 6709 We WV
op 7 ❑ ❑ Does the ground slope away from the water source site?? (show slope on plot plan)
3 -0M ❑ Is the well cap satisfactory? pen (op (Poly '0( fully were.
torgmsz ❑ Screened and vented? 100J
❑ The well casing extends above level ground I concrete slab? (circle one)
xI ❑ ❑ Is there evidence of a surface seal? Cqt 1133Y�liv3
X ❑ ❑ Does the seal appear adequate? LOA :— 121.95610Yz
❑ [� ❑ Is a variance necessary�� for well site approval? 145 tor 190
Comments /d/31/Zo73 - ke e4`� vtUureS O4 ?titter._ JJaYIdbef-hele
Pass ❑ Fail Inspector Date M/y/LO/Z?
Review Step 2: Two-Party Review:
YES NO NA
I1 ❑ ❑ Water Well Report with adequate pump test on file?
j' If NO, date of Capacity Test I Z((3/w fl. Driller Tin); cell or" GPM IS
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test IZ(�6/ ZZ
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 1(7 57
Y-" ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
TTTTTX Approved ❑ Denied Reviewer Date /17/1702 j
.----
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express
or implied ofthefuture 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 10, 2018 per ESSB 609I.
This form may be scanned and available for public view on the Mason County Web site. Revised: 1/17,2019
Page 2 of 2
WATER WELL REPORT ,, '‘: ] DEPARTMENT or Notice of Stern No.WE51438 --
ECOLOGY Unique Ecology wen ID Tag No.BMT 190 •
Type of Work: State of wasbington Site Well Name(if more thanone well)'.
0 Construction
O Demmmsn"n —2 Original installation NOl No. Water Right PermiUCcrtificate No.
Proposed Use O Domestic ❑llawlrial ❑Mbniapal Property Owner Name El KRISTYN AND SON CONSTRUCTION
U Ucweedng ❑Intgmion Cl Tea 9•e8 ❑abet -- Well Street Address 3770 EAST MASON LAKE DRIVE W_- - _-
CorhrtuctlonT3W: Method CityGRAPEVIEW County MASON
E New well ❑Alc aaan DJ Diet ❑Jetted CCble tool
❑Deepening D Other L Dug 10 Air- ❑N twnery Tax Parcel No. 22105-51-0025
olme"Aons: Diameter of boring 6 is ID60' _ _d. Was a variance approved[cc this well? ❑Yes ❑No
Depth of mvpleted well 59' D_
-- -- Ifycs,what was the variance for?- _ _ -
Casing Ition Depth: Well
Casing Lr¢r Diameter From To Thi[knees Steel PVC Welded TEnrcad - - Cl WWM or EIVM
IS 1 f1 6 @' SE_ 1f4 , 7 I IL P3 I ❑ Location(see instnotions on page 2):
11 I ❑ n, ❑ I ❑ ❑ I Ll SE 1/4-9e of Ow SE_rG;Section 32 Township 22N Rangy 2W
t I 1 ILi in. . n im ❑ I U IN I IN
❑ ❑ Inbmde(Example:47.12345)47 34717 -
_ ❑ ❑ - Longitude(Example':•1201R345) 122 95632
D. I•rrf d lJ\ hLN Type nfverf usedii. - - Driller's Log/Cm Ln¢tleno D DecommissionProcedure
\'o.olperforaa. 'ons Sma of Pnf n. in.5y 'n Fornufo :Descibe by color,rtaar.,,ive d struciate,arid the kind and
y P[rfonted from P,.to 6 balow ginnednu(rcn
nature teethe material in each layer penetrated,with at least wr curry rorach change of
1 K'Packer O Depth 68 R inlorrnaian lke additional shear if meteor,.
E.A Screens, VI Yes ❑No Material From To
Manufa:mreis Nano Johnson. -
Type SS Tele Model Nat' GRAVEL,SAND8CLAY TP IRRN) 0 48
Diameter 5 112' in. SIN sin 12.... in.foot
59_It to 59_a. GRAVEL 8 SAN TP W/B (BEN) 48 59
Dinntemr in. Slot ai,e_ 'm.(roar_ . II.to n. 60
$ '— GRAVEL,_ ,SAND (ERN) 59 f
Sand/Fitter park':❑Yee -id ND Sue of pad material in CLAY. -.. -.
Materials placed from _ft.to D.
u Surface Seal: iT Yes LP No To what depth? 18' 3. -- -
Material used in seal Bernariw _.
0 Did any seam contain unusable scaler? ID Yes Le No _
j Type"font? - Depth ofetnu -..
5 Method of scaling strata off_
j Pump: Manufacturers Name
D H.P. Pump intake deoh: f. Designed flu..rate: Fpm
L Water Leiets:Iand.surfaca elevation drove mean sea level -ft
-
Stick-up of top of sell casing i IL above ground surface
T. sou water level 24.4• R.below cop of well easing Date 1263/2022
Artesi _Os per squareinch Date - - - -
Artesianan water water is
mnlr"Ikd by _ -(c"p,"ahe,el.)
_
T Well Tests: _._.
- Wasa pumping test performed? ❑No O Yeses by whom?
] 'lucid _ _ppntwah_n.drawdown ader _hie.
Yie:d gpm w-:Ih_ R.dmvdown after hu. _ _ __ .-
A Yield gpm with IL dnwdosen aflvhrz
0 Recovery data(l irr -zero wbee•pump is mnwd off water level nruamrd Deo well
lop in water level/
n _
VITime Water Level Time u Water Level Time Water Levu
u - — —
3 Dale rp p g lest •
Raidi Net gpm t'M1 1.draw-0 n:after firs.
-- - - -_
jl Air 15 .gem with stem set al SE &for 2 hrs. U.tile 12/13/2022
Artesian Dow ppm
Temperature of water — E Woe a clwni[al analaars made I]Yes ❑No Start Dale 12/1312022 Completed Date 12/13/2022
] WELL CONS-rituC'tION CERTIFICATION: Icoustrnded and/or accept responsibility for construction of this well,and its compliance with all Washington well
as construction standards.Materials used and the informationreported above are ore to my best knowledge and belief.
❑Driller Cl Trainee❑IrP-Print Nano Dan Carpenter t Drilling Company TIMS Well Drilling
Address PO Box 14996 -
License No. 2236 - _ - -- City,Slate.Zip TUFDWOIoq WA 98511 _.
IF TRAINEE:Sponsar's License No. —_ - Contractor's
5punsais Signature
Registration No.TIMSW0834DN Date
__ - - W_ - - _ -'
ECV 050-1-20(Rev llll 8) lthor reed this document in an oilernate/rnmt,plea co call the Wafts Reso gm urces Prart ar
360 407-6822 Persons withhearing loss Call call 711 for IVasbiilgfoil Relay Services Per sons wid a speech disability can call
817433.6341.
Vanguard Laboratory
2635 Parkmont Lane SW
o' Olympia,WA 98502 '.
360.967.7010
VANGUAUt 1F Report of Laboratory Analysis
LABORATORY
Collected by:
American Pump and Drilling Matrix Drinking Water
360-754-7867 Laboratory ID: V221215-1
Sampling Address: Date Sampled; I211422 12;30
3770 East Mason Dr W
Date Received: 12/15/22 8:45
Crepavinv,WA 98546 Date Reported: 12/162022
Sample ID: 3779 East Mason Dr W
Analysis Result SDRL MCL Units DE Date Analyzed
Total Colifornl&E.eon by SM 92238(IDE7Jf) Batch ID:V221215-I Analyst:VJ
Coliform,Total Negative 1 I MPN/100 mL I 12/152217:35
E.soli Negative 1 I MPN/100 mL 1 12/1522 17:35
Nitrate by EPA Method 353.2 Batch ID:V221215-I Analyst:RS
Nitrate(as N)
ND 0.50 10.00 mGL I 12/16/2215:I5
•
Notes: i
MPN:Most Probable Number
ppm:parts per million ',
nd:non-detect Reviewed by Robert Smalling,Chemist on 12/16/2022
Na:not applicable
SDRL:State Detection Repnning Limit Approved by Ton Johnson,Operations Manager on 12/16)2022
DBDilution Factor ttit 17025,2017
MCL:Maximum Contaminant Level .. Page l oft
Samples we recieved in acceptable condition.The resents)in this report:elate only to the portion nf the rample(9 tested.All analyses farmed consistent
with the Quality Assnnnee program of Vanguard Laboratory Please.contact the laboratory if you should have any questions about the
s.
2635 Parkaiont Ln SW,Suite A,Olympia WA 985021 Office:360.9677010 1testing@vanguardlaboratory.com I
www.vanguardlaboratory.com
Name and Return Address:
1 / /- (Eti 2176571 MASON CO WA
I o t SE I2CEL VSGV C' I; 02/18/2022 10.05 AM NOTCE
BAILEY 8171232 Rec Fee $255 50 Pages 3
SEICea111) CCA cj IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Document Title(s)
1. /A-K7nce
2.
Reference Numbers(s)of Documents Assigned or Released
ADDITIONAL REFERENCE WS ON PAGE
Grantor(s)
1. JACCI J Ok'
2. ADDITIONAL GRANTORS ON PAGE
Grantee(s)
2. ADDITIONAL GRANTEES ON PAGE
Legal Description (abbreviated form:i.e.lot,block,plat or section,township,range,quarter/quarter)
�S 'MP
ADDITIONAL LEGAL IS ON PAGE
Assessor's Property Tax Parcel/Accounto Number(s)
coo ? dE' 22.tC5 -S( -CnDZCADDmONAL PARCELS'S ON PAGE
THE AUDITOR/RECORDER WILL RELY ON THE INFORMATION PROVIDED ON THIS FORM.THE STAFF WILL NOT READ THE
DOCUMENT TO VERIFY THE ACCURACY OR COMPLETENESS OF THE INDEXING INFORMATION PROVIDED HEREIN.
I am requesting an emergency nonstandard recording for an additional fee as provided in RCW
36.18.010. I understand that the recording processing requirements may cover up or otherwise
obscure some part of the text of the original document.
Signature: -C�.-��1 Date: 3 -702z
7* 3
Return To:
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned grantor(s),certify that the water source located on parcel situated in Mason
County, State of Washington,herein described. GR -. 2 S
3y«o ■ Range Township Section
Subdivision Division Lot
77
And having the Tax Parcel Number of: al a i6�---'- 3—�'- 00o--- '
Has been designated to serve a source of water to the following parcels situated in Mason County,State
of Washington; herein described: (abbreviated legal description(s) and tax.parcel au e''(s) affected)
OR
.3740 ■ Subdivision Division Lot qq Rangea l-� Township Section
And having the Tax Parcel Number of: d d-1 5-"J-I-- D 0.d d
OR
Subdivision
Division Lot Range Township Section
And having the Tax Parcel Number of: -- --
The system owner is responsible for keeping this system in compliance.
The name of the system is: IQ_
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 ranted -more waivers from specif provisions of the
regulations. I\ \ ^'
Signature of Grantor(s): ' (="
•
Printed name of Grantor s): --: L 3 `Dr \1eir-
Grantee: Public
Page 1 of 2
State of Washington (q'�p
County of Ma r Pital. v
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that n
on this jr___day of�l 20_�s\a�11n Of PI ? ``� eA vlrilSL� I"��
personally appeared before me, o is known to be the signer of the a ove instrument,an acknowledged
that he(she)(they)signed it.
Given,under my hand and official seal the day and year last above r written.
Ca et" / lt/
Notary Public in and for the State of Washington,
Notary Public State of Washington rt �r.Q(� f.� pp
CIERRA HAIRSTON Residing at 1�11(y L� Oily I)I U
NO.
MISSI 7991 My commission expires:•) I VI I ldti�
MY COMMISSION EXPIRES
JULY 29,2025
Page 2 of 2
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