HomeMy WebLinkAboutWEL2023-00056 - 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
'4,1 _ 1 Public Health & Human Services ELMA:360-482-5269,EXT400
FAX 360-427-7787
11/03/2023
WEXLER ET AL JENNIFER
430 W Homer Adams Rd
ELMA, WA 98541
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00056
430 W Homer Adams Rd
620181400020
The 2-party water system, AC0413 (620181400020/620181400020), 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,
Yv �
David Anderson
Environmental Health Specialist
Mason County Environmental Health
r
I
`' MASON COUNTY eR" " 10 - ( I - a,O„1,3
f Unit'';I?': COMMUNITY SERVICES A�U, R �
% Received v
`J 8, 16hng.P4nring,Emvmmenral Health Wvltx e
5_n O�nr /
415 N.G"Street(Bldg 8)-Shelton,WA 98584 WEL apa3 , 030 ar
Shelton: 360-0D-9670 x400 Belra:r.360-275-4467 x400 Elan:3 60-4 82-526 9 x400 '
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
Tey,n,P-ce-- w e Yler- Oct— gci3 - 3? US
MAILING ADDRESS 0STREET,Dn1 SjATETI1-Fr v1,er V -d,�-e c Rd EL✓tn.c wC. Q8-S �tI
SITE ADDRESS-STREET,CITY,STATE..f ZIP
S1ETVTT-5-E--
PRIMARY PARCEL NUMBER(WELL SITE) -` ��
r/a iOIIA— ILL. -O CJ
SECONDARY PARCEL NUMBER OF APPLICABLE) O ( S_ 1`I 'y - oQ 02O
S ei-Nra— C
WATER SOURCE SOURCE TYPE I PARCELLOT SIZE PARCEL 2 LOT SIZE
0 New I�Existing W Well ❑ Spring IL 6-,g-pyta 1E44
PROPOSED WATER SYSTEM NAME(REQUIRED)
ACo4f(3
PROJECT DESCRIPTION
13U2LC eJCLJ house, ) tktr) 2 dint it Mu6L(elfamtj-IIne,/\ 5Uuo
N P4,7 ADU
DIRECTIONS TO sue)CONDITIONS
S 'eAi-an MA*1oda_ kJ, -t-n T)PrkervLilt RA_ - leFt on Etomei
{tfin.s act . c e Pwst LucflsLAR.fL. . t1—ouW, 6n #kc )R-Ls)\--r
Site Plan: (may also be attached) '.
(properly boundaries.structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) ,ti
L,,i i L (Ia -
RECEIVED,
�.�.
I'll
<; n
Ir1
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 puma test or 4-hour capacity lest 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 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:
YES NO NA
D V ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ X ❑ 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?
V ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
in D ❑ Is the well cap satisfactory�fsc f�ed or t.&I
❑ X ❑ Screened and vented? �
❑ The well casing extends I( I above level ground/concrete slab? (circle one)
z ❑ ❑ Is there evidence of a surface seal? Ltd: C}•ii 1019,
X ❑ 0 Does the seal appear adequate? f_Oil: 173. j7%Og}
❑ 06 ❑ Is a variance necessary for well site approval?
/- 705; A02 4113
Comments Well Cop l� /IP cr tmi 1 _&il SQdCl
iief Pass ❑ Fail Inspectorv/ Date I'/ I/2O7 3
Review Step 2: Two-Party Review:
YES NO NA
X ❑ ❑ Water Well Report with adequate pump test on file? 7
`' If NO, date of Capacity Test Iig / ( Driller r l ' ail PM 2
5
14 0 ❑ Received Satisfactory Bacteriological Analysis? Date of test
FB ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Zz03 99
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments /�'��
V 7 7
`i Approved ❑ Denied Reviewer Date II /u[OZ3
Findings in this review relict,observed cmidition A as they existed an the clay of the cite in Spectio n. No claim is made,express
or implied°PIN,figure success or failure of Our.ssten.. 1I1,l/sire approval does of constitute water system approval Water
5r t in approval is a NV part process
.411 proposed connections to new wells are sub sect to water adequacy requirements at time of budding permit per MCC 6.68.
Water usage resoicnons and additional kes may apply to all new wells drilled alter January /911 20/8 per ESSE 6091.
Revised'. 10132021
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2
a
-EC1EIVEL
J. • 6 1T I WATER WELL R 6 PORT Start Card NO. W069401
Uni
Well I.D. II AC0412
` f TI SGRVIr STATE OF WASHINGTON Water1p Right Permit No.
31 OWNER: Name BELL, SANE Address 2669 WYMAN ROAD SW To0PII1, 1a 96511-
(2) LOCATION OF WELL: County NAO I - S[ 1/4 W[ 1/4 Sec 111 T 20N N.. R 6a6 WM
2a1 STREET ADDRESS OF YE]L for nearest address) gaaz ADAMS ROAD, WTICQ
Ill PROPOSED USE: DlRSTIC I10) WELL LOG
191 TYPE OF WORK', Owner's Number of we11 Formation: Describe by color, character, size of material
ial
(If Morethan one) and structure, and show thickness of aquifers and the
N[x WILL method: ROTARY and nature of the material in ach stratum penetrated, with
at least one entry for each change in formation.
(51 DIMENSIONS: Diameter of well 6 inches
Drilled 36 ft. Depth of completed well 36 it. MATERIAL PROM TO
- — SANDY BRIM[ CLAY GRAVQ• 0 17
(61 CONSTRUCTION DETAILS. OKAY SHAM GRAVE. a WATER 17 16
Casing ia talled: 6 . Dia. from a1 ft. to 36 ft.
WELDED CA6040 . Dia. from ft. c fL,
' Dia. from ft. to ft.
Perforations: WO
Type of perforator used
SIZE of perforations in. by rn,
perforations from ft et
perforations from ft. to ft.
perforations from ft. to ft.
Screens: NO
Manufacturer's Name
Type Model No.
Diam. slot size from ft. t et,
Diam. slot size from ft. to It.
Gravel packed: NO Size of gravel
Gravel placed from ft. to ft ra
Surface seal: YES To what depth? 20 ft.
ial used inE
seal
BTONITE
Did
strata ntain unusable water? NO
Type of water?
Depth of strata ft
Method of sealing strata off
h) PUMP: Manufacturer's Name
Type N,P,
1.61 WATER LEVELS: Land-surface elevation _,
above sea level [C,
Static level 4 ft. belowe top of well Date 01/06/97
Artesian Pressure lbs. per square inch Date 1
Artesian water controlled by I
I work started 01/06/91 Completed O1/05/91
191 WELL TESTS: Drawdown is amount water level is lowered below WELL CONSTRICTOR CERTIFICATION:
static level. I constructed and/or accept responsibility for con-
a pump test made] NO If yes, by whom?
ccion of thin well, and its compliance with all
e gal./min with ft. drawdown after hrs. Washington well construction standards. Materials useds
'field: and the information reported above are true to my b
knowledge and belief.
Recovery data
water ater Level Time Water Level Time Water Level NAME ARCADIA DRILLING, or corporation)ING INLC Type or print)
ADDRESS 9 1T0TO x
testADate of / / I License No. 1149
25 sailer test /a1/mi et. drawdown after hrs. [SIGNED]
Arr test fl 9a1/mi w/ stem Set at 30 ft. for 1 hrs. Contractor's
Temperas flew 9.p.m. Date
Temperature of water Was a chemical analysis made? NO Registration NO. ARCALOZ096[1 Date 01/09/97
i oiled I ": or Mason Chou lty i_7,,,,I,..
Thurston County Environmental Health
2000 Lakeridge Dr.SW E Olympia,WA 98502
360 867-2631
nunsON COIN
COLIFORM BACTERIA ANALYSIS
Dale Sampie Collected time Sample County
Col acted
2 ' ' ?me, Day e3 _ on
" Mo
Type of Water System(check only one box) Private Household t����,1'
❑Group A ❑Group6 ]Older5I MjIE A144,
Group A and Group B Systems-Provide horn Water Facilities Inventory(WFI).
ID4
System Name:
Contact Person
Day Phone ( ) Cell Phone'( )
E-mail: Eve.Phone:( )
'Send resale to(Pent lull nnie.address and zip coca or email nddrOs)
t- at _12Q-Ltttmwc CAM
SAMPLE INFORMATION
Sample collected by(namel 0-ennticr Wtx
Specific location or address where sample collected: Special instructions or comments
• 43o W. HvmeC �CL.4nC
Type of Sample(mustcreheck only one box of el through A4listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unset.routine)
Chlorinated:Yes _No ❑Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No_
1.Raw Water Source Sample Chlorine Residual Total Free
❑E.toll-GWR(AIP)
❑Fecal-Scone GUI roegetremai oat Unsatisfacery routine lab number.
Falered Yes No
0 Assessment Monitoring{A/P) Unsallstactory routine collect dare
❑other
4.4 Sample Collected for Information Only Investigative Construction_ Construction 1 Repairs Other LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY
❑Unsatisfactory Total Culilorm Present and o Satisfactory
❑Ecob present ❑Emli absent lilwm deletled
Replacement Sample Required:
❑Sample too old(>30 hours) INTO ❑
Bocterial Density Results:Total Coiilonn_ /100m1 Ecoii_ /100mi
Fecal Coli one
"" Ilooml Emerococcl /100 rill.
Method Code fwM 9229E ❑SM 92720 wls andnd Tine Received
❑SM 92158 0 Enlemle� 8 1-Z3 p IllS'�-
`Dale and Time Analyzed- at 1- Z3 Oats Reporle $ ),
amp
le Nemec I DcW onto plus les Komi I Lab Use Only
0 8 0 I L '27 7 r _
L
,»r2c;C�5Fawe.
rr 313a54
2203249 MASON CO WA
10/11/2023 01 06 PM NOi6E
JENNIFER WEXLER 14191539 Rex Fee- $204 50 Pages. 2
III 11111111111111111 1111111111111111 I III IIII III
Return To
C-f,nn1Par 1.J &( er
430 W, ave./ 4,nev.s
US91
Grantor(s): (1) Ten Wc-Bir UJtxk/ (2) 3 A.UU.n naliN rtr1f. et S
Grantee(s): (1) PUBLIC 5 18 TLO R(, /
Legal Description (1) TK 2- of Si/2.- NE c uRvc y s o ( t )
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 4 2 0 t 9 - t 9 - V O C) a O
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) & 2 C) g - I. l'4 - 0 0 C0 2- O
Tax Parcel: (Connection 2) (p Z O 1. K - 1. 1 - 0 U U 2. 0
The system owner is responsible for keeping this system in compliance.
The name of the water system is: A CO 14(3
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 t ) day of QL ✓ , 201.S.
Signature of Grantor(s):
(1 (2)
/�C Page 1 of 2
State of Washington
County of Mason
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
rr--certify that on this day of DC--6b(r , 20j-
-kiln OE\'SritC(ir appearedrsonally 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 writte .
"\\otitimausiit ' Notary Public 1i�n and for the State of Washington,
vl residing at 1 ov\ ✓>�'y
��% My commission expires: l,t�� 'ZQ
•
NolOw
acir
Page 2 of 2
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