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Home My WebLink AboutUntitled (2958) ON, MASON COUNTY 415 N 6TH STREET,SHELT967 , EXT400 SHELTON: 360-427-9670, EXT400 BELFAIR: 360-275-4467, EXT400 144 Public Health & Human Services ELMA: 360-482-5269, EXT400 FAX:360-427-7787 DEBRA TRIPLETT 13330 Lester Rd NW SILVERDALE, WA 98383 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2017-00033 3770 NE Bear Creek Dewatto Rd 123065001002 The 2-party water system, TriplettlDegarimore 2 Party Well System (123065001002/123065001003), 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 ammil .,,,,.,,s..,,,,:,:::, MASON COUNTY Date Received �''' `'F RR. COMMUNITY SERVICES Amount Received: Received By, Building Planning,Environmental Health,Community Health + 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L Z 6 (` ' - U 6 v 3 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPUCANT r PHONE rl..hr..Tr'r.l..4+ I-aan 71 n. A A OO IJGUI a l 11'JIGLI I JIJ V-I I V-TTIJv MAILING ADDRESS-STREET,CITY,STATE,ZIP 13330 Lester RD, NW Silverdale WA 98383 SI I t AUDHtSS-S I Ktt I,CITY,STATE,LIP 3770 WE 6ea ri f IL Pew ffa rid, ge(fcer Wft Fg5 ze PRIMARY PARCEL NUMBER(WELL SITE) 12306-50-01 002, Well Head is located just over property line on 12306-50-01 00200 1 002 SECONDARY PARCEL NUMBER(IF APPLICABLE) 12306-50-01003 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑New Ei Existing to Well 0 Spring .65 Acres .43 Acres PROPOSED WATER SYSTEM NAME(REQUIRED) Triplett/Degarimore 2 Party Well System PROJECT DESCRIPTION 12306-50-01002 will be primary residence. 12306-50-01003 will a seasonal parcel DIP.Ec,,,,,.,,TO S,^,G'CONDITIONS 3770 NE Bear Creek Dewatto RD t Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easeme s,etc...) See Attached FEB19 � 74 RECEIVED FEB 2 S 7024 , By Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) 12 Weil Log with pump test or 4-hour capacity test performed by driiier(this may be deferred if weii is not yet drilled) 0 Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) G1 Septic Records(additional locating renuirements 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 i of 2 .....------..........-------.........----------Staff Use Only — Review Step 1: Well Site Inspection: YES NO NA E ()�I [1 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. Whet ib distance to ROvv? • 171 A❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) t4 16 ❑ is the weii cap satisfactory? ., (ytm '4`t- h O tK/ 4 ❑ ❑ Screened and vented? �Il Li The well casing extends 1 above level ground/concrete slab? (circle one) J ❑ ❑ Is there evidence of a surface seal? £U4 ' `i? 57?o6sy fs' ❑ ❑ Does the seal appear adequate? LUG: —I Z Z'$tI`11S?$ ❑ (r ❑ Is a variance necessary for well site approval? ( (IQ•,,BX8,579 Comments O Carawf Itd f Carreap,o{ 37f/z0Zy yPass ❑ Fail Inspector /-tt...-- Date Z/��/ Z 02 i/J Review Step 2: Two-Party Review: ' t YES NO NA 600 yet OW) X ❑ ❑ 'Wier Weii Report with adequate pump test on file? I If NO, date of Capacity Test "l t t (Zu[z' Driller Aviv pp / GPM 5 K ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ES Z `( gr ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN • q i` -10 AT ❑ ❑ System appears adequate to serve 2 single-family residences based on informationon-et/pr .provided? 7 Con,merits /� Mt_ CUII/1L Yao pd � Coll/cc'1 ✓re ivrr WIZ/€ i � V ct K npprovcd n nnnied Reviewer PL„/----- Date L Ci/ 20 V �/ ` I I F flutingsinthis 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. 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 19`h, 2018 per ESSB 6091. Revised: 10/i 3/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 Y WATER WELL REPORT CURRENT RECEIVED Original&I"copy -Ecology,2~copy-owner,3r4 copy-driller Notice of latent No.W E29401 JUN 01 Z018 otroxisla'01 ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. BKH579 IN Construction Water Right Permit No. WA State Department ❑ Decotttmission ORIGINAL INSTALLATION of Ecology (SWRO) Notice of Intent Number WF.29401 Properly Owner Name Triplett/Degarimore PROPOSED USE: ® Domestic 0 Industrial 0 Mraricipal Well Street Address 3770 NE Bear Creek Dewatto Rd 0 DeWater 0 Irrigation 0 Test Well 0 Other City Belfair County Mason TYPE OF WORK: Owner's number Orwell(if more tkan one) iii • New well 0 Reconditioned Method•0 Dug 0 Bored 0 Driven Location 030`4-114ne U4 Sec 6 Tart 23n R lw F.WM ❑ Deepened DJ Cable ❑ Rotary ❑ Jetted is I.r Still REQUIRED) Or WWN MI DIMENSIONS: Diameter of well 6 inches.dolled 477 ft. Laul.ong Depth of completed wcll94r R Lat Deg Lat Min/Sec CONSTRUCTION DETAILS Long Deg Long Min/Sec Casing ® Welded 6 - Duo,.from +1 IL to 472 ft. Tax parcel No.(Required) 12306 50-01002 Installed: 0 Liner installed " Oiam.from ft.to fl. 0 Threaded " Diam.From ft.to ft. Perforations: ❑ Yes ® No CONSTRUCTION OR DECOMMISSION PROCEDURE . Type of perforator used Formation:Describe by color,character,size of material and structure, and the kind and nature of the material in each stratum penetrated,with at SIZE of perfs_in.by_in.and no.of p ifs_from_ft to_fl. least one entry for each change of information. (USE ADDITIONAL. =at Screens: 0 Yes 0 No ■ K-Pae Location 470 SHEETS IF NECESSARY.) Manufacturer's Name Machine Alloy Works —_ __ MATERIAL. FROM TO Type Stainless Model No. Topsoil 0 2 ti Diem.s Slot size 20 from 472 ft.to 477 ft. Hard Pan light brown 2 20 c Diam. Slot size front ft.to ft. Sand&Gravel w/Water 20 40 o — o Gravel/Filter packed: 0 Yes I! No Size of gravel/sand light brown hard pan 40 80 Materials placed from ft.to ft. _ blue tight sand and gravel w/water 80 155 ?zo light brown hard pan 155 270 o Surface Seal: II Yes ❑ No To what depth. fl. M t Material used in seal atataaite __ light brown hard pan w/water 270 275 ` Did any strata contain unusable antler 0 Yes ❑ No reddish brown conglomerant 275 320 0 Type orwwer Delnth arstrata Red Clav 320 370 oMethod of seating straw on .- light brown hard pan 370 440 O PUMP: Manufacturer's Name Grundfos _ silt bound sand&gravel w/water 440 475 o Type,sub H.P. 3 sand&gravel w/water 475 476 IWATER LEVELS: Land-surface elevation above mean sea level ft. C,rcv Clay_ 476 ° Static level 434 Il.below top ufwclt Elate 4/21/2018 5cp Artesian pressure lbs.per square inch Date 7 oo Artesian water is controlled by (cap,valve,etc.) 3 W£.I.L TESTS: Drawdown iv amount water lend is lowered below static level ~O Was a pump test crude? Ill Yes 0 No !ryes,by whom?Davis - -- 2 Yield: 15 col./min.with 443 ft.drawdown after I Ms. a Yield: gal./min.with ft.drawdown after hrs. Yield: gal./min.with_ft.drawdown after hrs. Recovery data(time taken as zero nitro pump turned op)(later level measures/from v w well top to water level) w Tinre Watra LC VC) Time Water Level Tiixw Water Level o 0 mn 443 3min 434 t 1 l 437 2 435 $ Date of test 4/21/2018 2 Barkr tear galimin.with_ft.drawdown after_his. h .Air est gtl.:min.with stein set at ft.for Dos. Artesian flow gp.m. Date i Temperature of water Was a chemical analysis made? 0 Yes Ill `:o Start Data/6/18 Completed Date 4/19/2018 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. ®Driller❑Engineer 0 Trainee Name Emily Davis Drilling Company DAVIS DRILLING Driller/Engineer:Trainee Signature Address 340 NE Davis Farm Rd Driller or trainee License No.3142 City.State,Zip Relfair,Wa 98528 IN TRAINEE:Driller's License No: Contractor's Drill cr.sSignature: Registration No. DAVISDI110OA Dale 4/20/2018 ECY 050-1-20(Rev 02-2010) To request ADA accommodation including materials in a format for the visually impaired,call Ecology Water Resources Program at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call 17Y at 877-833-6341. 26276 Twelve Trees Ln NW Ste.0 SPECTRA Laboratories - Kitsap Poulsbo,WA - —Where sapertaau maulers 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM • Date Sample Collected Time Sample County 2 II iq Collected I el 6 Di Wall Vox Type of Water System(check only one box) qq� ❑Group A ❑Group B Y r ott e Th VOl Tv Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): IDit -7 /� �y, �,,�,,(� System Name: 3 J 70 I VL .y Q(/ll�6114_ awa Contact Person: Day Phone: Cell Mona Emai: Eve.Phone: Send results to:(Pal Silt nano,added nd zip code or canoe above roe.kcbonk copy of multi) iSdi1i _Uniw-d SAMPLE INFORMATION Sample collected by(name): '' 1 ( „ Specific location where sampl collected: Special instructions or comments: Wk\, Type of Sample(check only one box) 1.❑Routine Distribution Sample(ASP) 2.❑ Repeat Sample(ASP) (from distrrbubon system alter unsat.routine) Chlor Hated:Yes ❑ No 0 Unsatisfactory routine tab number. Chlorine Residual:Total`_Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect dale S I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total— Free---- ❑Assessment(AN) 4.Surface or GWI Raw Source Water Sample(Enumeration) ` S I I ❑ E.cod 0 Fecal Foxed Yes No 5.[ ,Sample Colected tot Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and „flitgatisfactory ❑E.cot present ❑E.cot absent Bacterial Density Results:Total Conform mpn/100m1.E.coli_ mpn/100m1. Fecal Calm, cful100m1. HPC __cfu/tml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ -- --- Lab Reference N mter 13a0 1,2)('IQ �I Receipt T2.0p(•; Method Co 38! -COUFIT/SM92220 t 41 �p,��.��,• (fit �npalr Y.ad ed.htraw uaaar�ameoxwn 1 Lp.1 5 2UL• 161 6 ‘ axe ao.dtrwwd Any w,mina or dxkess ohs/caner Po flooded wiponlh msulhotest./sou nne wowed M mod ea, h.Mi prr noel di'motherly r3 yo 7795141 we)olwo/Pis opal pa'.De/ DOH LabSaaarellee�)# V e O ) Thom minis Wale bV h lapse xae tidM hrrONy au0r 010 I,5iso *,oealoa"M. w WI,recut pro alphas Been eypar h sd.me rthxrnk. son Few S3311191rww aun7) Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C ...Where experience waners Poulsbo,WA 98370 Phone: (360)779-5141 www.spectra-lab.com Spectra Labs - Kitsap, LLC (Poulsbo)received samples for Davis Drilling on Thursday,February 15, 2024 at 1:00 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures.A summary of the samples received are outlined below. Sample No. Description Location Sampled 236907-01 3770 NE Bear Creek Dewatto Rd Well Head 02/14/2024 16:00 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.spectra-lab.com. Attachments 01) This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized. If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 02/20/2024 Page 1 of 1 y ,c 2093477 iMASON CO WA Ih11A ofi iiitiIIIlln11ii1iiiiiinii iii11iiiii Return To: Debra Triplett,PO Box 556,Seebeck Wa 98380 John Degarimore,C10 Beth Payne 861 NE Mt.Mystery LP,Poulsbo WA 98370 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned,certify that the water source located on parcel situated in Mason County,State of Washington,herein described. PANTHER LAKE TRACTS BLK:A TR 2 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of: 12306 -- 50 -- 01002 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 and tax parcel numbers(s)of property(ies)affected ) PANTHER LAKE TRACTS BLK:A TR 2 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of: 12306 -- 50 -- 01002 PANTHER LAKE TRACTS BLK:A TR 3 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of: 12306 -- 50 -- 01003 The system owner is responsible for keeping this system in compliance. The name of the system is TRIPLETT/DEGARIMORE 2 PARTY WELL SYSTEM This system is designed to provide for two services. 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. :-- Signature Signature State of Washington County of Mason I,the undersigned ,a Notary Public in and for the above named County and State,do hereby certify that on this I$ day of ttJs0.>-?� ,20 t$ , Derova L-•Tt rr,,��\� pe sonally appeared befor me,who is known to be`s�ner of the above instrument,and acknoMedged that h=(0)they)signed it. GIVEN under my hand and official seal the day and year last above writjet._ adt1/4.19.:tr Notary Public,.in and for the State of W hington 'f`)h�te ' 1 Ll) ��,1E Ci 14 e%' residing at ,)11 Vi rC CU Q. - `ystOH�LtfrRO ��j/ My commission expires: (Lpq/�O �01,1 tee(i 0d� R� (pi N� 4/g1G c O /''a. .29-2,0 4 �/9zr I�oF WASH\a�` fflltt‘>,‘‘‘‘‘‘`‘`.. 2093478 MASON CO WA 06/01/2018 11:16 P.M NOTCE TRIPLETT #114433 Rec Fee: $74.00 Pages 1 1 IIIIII 1 III II I IIIIIII IIIII IIII II IIIII IIIII IIIII I II IIIII IIJI IIIII IIII IIII Return To: Debra Triplett,PO Box 556,Seabeck Wa 98380 John Degarimore,CIO Beth Payne 861 NE Mt.Mystery LP,Poulsbo WA 98370 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned,certify that the water source located on parcel situated in Mason County,State of Washington.herein described PANTHER LAKE TRACTS BLK:A TR 2 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of: 1230,5 -- 50 — 01002 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 and tax parcel numbers(s)of property(ies)affected) PANTHER LAKE TRACTS BLK:A TR 2 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Ni.mber of: 12306 -- 50 -- 01002 PANTHER LAKE TRACTS BLK:A TR 3 OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of: 12306 —_50 -- 01003 The system owner is responsible for keeping this system in compliance. The name of the system is TRIPLETTIDEGARIMORE 2 PARTY WELL SYSTEM This system is designed to provide for two services. 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 s stem (has/has not) been granted one or more waivers from specific provisions of the re• ors. � i ignature , Signature State of Washington County of Mason undersigned,a Notary Public in and for tie above named County and State,do hereby certify that on this qhh�� day of r�ul,c,`, ,20(t) Ohl' 0. VP,Vei MQYL personally appeared before me,who is known to be signer of the above instrument,and acknowledged tJat he(she)( y)signed it. •- GIVEN under my hand and official seal the day and year last above written Notary Public Notary Pub i an f r h ate o Washington State.of Washington residing at �irr ►� My commission expires JENNIFER K. RUCKMAN MY COMMISSION EXPIRES July 4,2018 Ur qb aM Jlalla9 0. /UMr•p/q/.f, , BLSQb QM'Jqu}PQ Et l xog'cid:ssalppy wol ooyerypiglas'id OWL-61,9-09E PeOS 041entioCI)I2aJ7 Jen 3N OLL£ „a! w1 ciao :I104.4.3 all'N9153a A9-135 :ssaippy an :MOa N9153O N Ai_ / / , , AvW .. / 1 04 i �� hN, 3 4 --- , .4!) al V-- 1 t c 2 h �y tif , 4 N 4 0. 4 . • �'� w A* un o p ��, p m - �. m O °W 3 - in z a� _ ~ 4) N In \ , 3 V Q W m p RI 0. cy o o IY7. fr.' ,r os It '.-ri V,y i l/ / ` ,• ` V V l0 3 — i I 8' ) ILN 3a 6 ^ c r) '4.•-, , 1 „,* V 4A4110 0p 0 -C --{ L- �� - C J l0 y I. Ili -- r } ? a + e 1 r 3 v 0 Q :___,_ 1 1 , u h c� a CI • �� i L ! 4! �_-- o .r p„ O L. 1 != i W a 11\w�,,��el I 0 Z H IN _.--- • ;. 7,1 � 4`` / z5 c to I 03 com L 13 °' 0 MI V 4� Q ` 1. �` '.ti ';=" 4"'� ILL ----1—/....._ 0' eek Pewatt0 ROad ' tn a NE sea Gr a