HomeMy WebLinkAboutWEC2023-00066 - WEC Application - 6/5/2023 a
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„„,\, ..,,,.„„,,of MASON COUNTYJuN 05 2023
;z3 , 11" COMMUNITY SERVICES
.� 27�1,‘a � Building,Planning,Environmental Health,Community Health
BY
415 N 6th Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 •• Elma:(360)482-5269 ext 400
FAX(360)427-7787
NOTICE OF INTENT TO DECOMMISSION A WELL _
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Numbers .J 2. Attach a plot plan and vicinity map.
a0,93 - ❑ Cash 3. Submit this completed application with appropriate fee a
❑ Check minimum of 24 hours in advance of initiating well
C-'of n f_� decommission. Refer to Mason County Environmental
Date of Payment LY `� Health fee schedule for cost.
4. Mason County Public Health must receive notification at
• least 24 hours prior to the decommissioning of the well.
PART 1: Applicant/Parcel Identification /�
Site Address ')gc)lO f - St• R Jo CO Start Card# ive 7e 2:7
Drilling Firm CV S 0IrI60 Phone 3(Qc)'pc))� 75
Applicant 0 \AJ LL, Oiyt.Q Phone 3e0-
Mailing Address 12_ C 171 CU�')-tLt'
¶ t A W 0`
ClS 77A
Citytate .AI
Sr�.�-lam , �/� AZip
Parcel Number T 2-J Q(.•Q — 12-00 U 7 0 i ,/�� /` p^,, /
Directions to Site IC\ It D, r2 0`,\ 1 'kJ El 5% • (Li I V Le 0 ) "`�
Le, Ue kw ea, EVu rat/ Cu In Uviit_?y
Is the well being decommissioned to allow siting of potential source of contamination (ie. septic drainfield)? ❑Yes ❑No
If yes, a variance from^DOE is required. Have you applied/received (circle one)a variance? ❑ Yes ❑ No
"�l
Applicant/Agent Signatur
PART 2: Health Department Review(Staff Use Only)
YES� NO TAG# 3p U 3R V Called In i 1 I 23 F'"2 `IS jz3
la` ❑ Driller on Site?
CU El Has the well been decommissioned in accordance with WAC 173-160?
❑ Is this a cased well?
❑ Is a well report available that shows a surface seal? 40
/ -
Method of Decommission R. CLAS j •f II 10�U0 / �o fie- - �
and Comments lei) 1 peh+c'n i-�- �j/tt S
\\3f eA„i N� w t-;--).4 b Iz,N uo i'l 3S -SAC-1 o id 'tekri o,NJ t ' C.tl►P Pt.�b Cb. (hi o St_) C-2.1l
❑ Pass ❑ Fail Inspector J e%O`IM D4 l &cv t 5 ire.r4&> Date {9112- (2-3
This form may be scanned and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Decommission a Well.docx Revised: 1/20/2017
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i WATER WELL REPORT 0tPAI'kit"' `,i Notice of Intent No. WE48333
ECOLOGY 1lniyue Ecology Well II)Tag No. BPU 398
Type of Work: State tit Wasbngtn r
O Construction Site Well Name or more than one well): N/A
0 Decommission =o Original installation NOI No. Water Right Permit/Certificate No. N/A
Proprtcrl Use: L Demrostic J Industrial =Municipal Property Owner Name Dwell Homes LLC
C Ir.7.ak:nng Z.Irrigation 0 Test Well —Other Well Street Address 3990 E State Route 106
Constnactlon Type: Method:
od:
i.,New cell C.1ltcratito E Driven C Jetted Ft Cable io,,i City Union County Mason
:)Ito puling C O11Cr =Dug C Air- C Mud-Konen "fax Parcel NO. 32106-12-00030
Dimensions: lhameter tilhorina 6 in..to 118 it Was a variance approved for this well? ''Yes E No
Depth ofco npleted well 115 It
If yes,what nits the variance tor? N/A
Construction Details: R'all
Casing Tina Diameter Front 'fir Thickness Steel PVC Welded Thread
e in. 1 flee e2e in. _ 1 E Lueattutt(sec instructiotsut page 2). V WWM or❑I:WM
C ill. ^ um. J u ❑ C NE '/%ofthe NW '/;Section 6 •lowltship 21N Range 3W
C• C , E in. in. J ❑ ❑ C.:in. in. J ❑ ❑ C Lntit le(Exampl«47.12345) 47.34484
Longiusle tli'anpte:-120.12345) -123.108343
Perforations: J 1'c. _N\te 1'.paof'patixatofu.cd Driller's Log/Construction or Decommission Procedure
No of perforations Ito Sue ol'p.-koratiuus_in h._tit Fannatitm:I>tacribe by color.character.siz.,of material and structure,and the kind and
Perkxakdfrom n to a It below grand surface nature ot'the material in each lays-penetrated;nidt at beast tine entry for cash change of
Screens: T'I., IC i.-P..eee.t '•' Depth lea tl intor ation. t'.e additional sheets ifns erwn'.
\lannlaclutta's Name Johnson Material From 'Its
Typo Stainless Steel Wire Wrap Model No.Diameter 5 in Skit s ze 25 in.from 115 ft.to 110 it. Top• Soil OR 2ft
2ft 211
Diameter in. Skit sue_ in.front_11.to 11. Brown Till
Brown Clay 14ft 21ft
Sand/litter pack:C Yes a\o Size or pack material_in. Brown,Silty Sand&Gravel 21ft Sift
Materials placed from_11.ao_Il Brown Sand&Gravel(Wet) 51ft 53ft
Seal:Surface EYes 'i No T w o hat ti l+th'' 19.5 IIBlue Clay wi Gravels(Wei) 53fi 59ft
Material used in'cal 8enk nfte Clay Cttlps Brown Clay w/Gravels(Wet) 59ft 85ft
Did any strata contain unusable water? =1'cx r No• Brown Conglomerate `811t 89ft
Tyre:of moo-, Dural of.rota
\lcihod of sealing scam off Brown,Silty Sand&Gravel(Water Bearing) 89ft 92ft
Brown Till 92ft 101ft
Pump: \IatinfacturT's Nnm Franklin type Surnbersible• Ground Sand&Gravel(Water Bearing) 101ft 115ft
Ill'. 3/4 Romp intake depth.80 n. DCSigood flow rote. 15 gpm
water I.a-sets: land-surface ekvhmm nbnee moan wit level 24 tl -
Stick-up of kip of well casing i2 11 above ground surface
Static water level 34 fl.below'lop ofweil casing fate 7/23/2022
.\)tesian pressure_lbs.per square inch fate
Artesian water is potroltod by (cap.vahe.etc.
Well Teats:
Was a pumping test psalioned? R No J Yes Ci In nhoin'
Yield ppm%silk_11.drandossn alter_hrs.
l ield emit with 0 druwdonn alter_hrs.
Yield spat nitli tl.dravdotsn alter_hrs.
Recovery data(lime zero when pump is turned off haler level measured from well
top in stater here))
Time Water Ic.'d Time Water Level lime Water level
IMtoofpumpng led_Miter test 15 gpm with 43 II.drawdow n after 4 hrs.i
Air Zest_gpm with atom set at ft.for hrs. - Date 7/23/2022
Artesian(bon_gpm
• tenip Tama:of water_`F \1'ns a chemical analysis made'? 0 Yet. W.;No Slur)l)Ulc 7/5/2022 Completed I)ate 7/23/2022
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WELL CONSTRUCTION CERTIFICATION: I eonstnicted and/or accept responsibility fix construction olIhis cell.mid its compliance with all Washington well
constntction standards.Materials used and the information repotted above are true to tits lone knowledge and belief,
'�Driller 0 trainee=I'E—Print Name Dwane Knapp 1 killing Company Knape Drilling ins
• Signalure Z7-Qair - /t f4/0,- Address 50 E Lesaca Drive
License No 1706 ' City,State,Gip Shelton,WA,98584
IF TRAINEE:Sponsor's License No. Contractor's
Sponsors Signature Registration No.KNAPPD1952B1 l A t 7/26/2022
EC Y 1)5)-1-20(Rev tih/I tJ)11 you nerd This document in an ahernate J,wmat.please call the II urer Resources Program a1 till-41)1-n.\-2.
1'e wass with hearing lets can call 711 far I f iashingavi Relay Service. Persons with a.speech di.uthllin'can call 877-S33-6341.