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Home My WebLink AboutUntitled (2959) frA MASON COUNTY 415 N 6TH STREET, SH TON, 8584 SHELTON 427-967 , EXT40 BELFAIR: 360-275-4467, EXT400 4 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, Triplett/Degarimore 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 MASON COUNTY Date Received. • r°177 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 O Cl- - U 6 (2) 3 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPIJ CANT PHONE rlL. ..T '.+L.« I'Ian 74 II A QQ LJ IJIQIIIJIGll 1 dVIJ-I IV-'TTVV MAILING ADDRESS-STREET,CITY,STATE,ZIP 13330 Lester RD, NW Silverdale WA 98383 SIIEAUUKESS SIKEEI CITY,SIAIE LIP 3770 WE 6ecrcre_ek Dev tFc Rd, Beffctr Wfi 7552e PRIMARY PARCEL NUMBER(WELL SITE) • 12306-5U-U-I002, 'Weil Bead is located just over property line on 'i 23Ub-5U-U 1 UU2U'i UU2 SECONDARY PARCEL NUMBER(IF APPLICABLE) 12306-50-01003 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑ New M Existing la 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 DYZC,oNC,OStTG'CO O:,,ONS 3770 NE Bear Creek Dewatto RD I 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 �ati' FEB 292,, . RECEI vE.D I 1 1. LbII1 \'il1 l FEB 28 2024 I I Submittals Checklist: (these additional items will be required for approval) 0 Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) 2 Weil Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) L3 Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) GI 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 n 1-71 [ 1 Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ ti6 ❑ 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? Mifip ❑ Does the ground slope away from the water source site? (show slope on plot plan) "' u is the well cap satisfactory? ., OM Cfri`-v4(f- h a tt 4 ❑ ❑ Screened and vented? ❑ The well casing extends l above level ground/concrete slab? (circle one) V ❑ ❑ Is there evidence of a surface seal? L G(,rl1 : K?.si906sy ❑ ❑ Does the seal appear adequate? (Lull: I z Z,S ti”S9f ❑ I ❑ Is a variance necessary for well site approval? I ,Dcri,'7q Comments OM/ CjVWYf C , ((%('hole i7.X/ZQzy L�( Pass ❑ Fail Inspector /01- Date Z /z�12 0 2 1/d Review Step 2: Two-Party Review: YES NO NA 600 el fo40 X ❑ El Water 'eveii Report with] adequate pump test on iie? ✓ If NO, date of Capacity Test "l uq(rW1g Driller Djv(S 4 GPM / 5- ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test IS ZMK ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Y 1l 20 x ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Corr]nients J Cad Cvlin'4 foo y pd pet Cofince r'e oz . 0 Z/ )z -t 'Approvcd ❑ Dcnicd Rcviewer /// 4( -- Data 3'/ 41/ ?c (/ ti, I Frndcngs in this review reflect observed conditionsas 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', 2018 per ESSB 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 CURRENT RECEIVED Original&I"copy-Ecology,2w°copy-maser,3'4 copy-driller Notice of intent No,WE29401 _— �� (� 1 U urr•nre. u v 18 ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. BKH579 ® Construction Water Right Permit No. WA State Department ❑ Decommission ORIGINAL INSTALLATION of Ecolo jy (SWRO) Notice o f Intent Number WF.29401 Pn'peny Owner Name Triplett/Degarimore PROPOSED USE: ® Domestic 0 Industrial 0 Municipal Well Street Address 3770 NE Bear Creek Dewatto Rd 0 DeWatcr 0 Irrigation 0 Test Well 0 Other City Belfair County Mason TYPE OF WORK: Owner's number of well if more than one) IN Ili New welt 0 Reconditioned Method•0 thug 0 Bored 0 Driven Lsxation�yl`4-1J4ne 1/4 Sec6 Twn 23n R 1W F.WM ❑ Deepened B Cable 0 Rotary 0 Jetted is t r Still RF.(?UiRF,D) Or WWM IN DIMENSIONS: Diameter of well 6 inches,drilled477 fl. Lat/Long Depth of completed wctl9/n R Lat Deg Lat Min/See CONSTRUCTION DETAILS - Long Deg Long Min/Sec Casing ® Welded 6 - Dom.from +1 n.to 472 ft. Tax parcel No.(Required) 12306 50-01002 Installed: 0 Liner installed " (ham.from ft.to R. 0 Threaded - Diam.From ft.to fl. Perforations: ❑ Yes ® No CONSTRUCTION OR DECOMMISSION PROCEDURE used Type of perlinator Formation:Describe by color,character,size of material and structure, $ and the kind and nature of the material in each stratum penetrated,with at SI7l!of perk_in.by_in.and no.of perfs_from_fl to ft. least one entry for each change of information. (USE ADDITIONAL 3 Screens: 0 Yes 0 No IIIK-Pas Location 470 SIIL'ETS IF NECESSARY.) 3 Manufacturer's Name Machine Alloy,Works____ __ MATERIAL FROM TO Type Stainless Model Nu. Topsoil 0 2 c Diam! Slot sin 21' from 472 ft.to Q7 ft. Hard Pan light brown 2 20 0 4 Diam- Slot sire (mar ft to ft. _ _ Sand&Gravel w/Water 20 40 _ o GrareUFitterpacked: 0 Yes ® No Size ofmod/sand light brown hard pan 40 80 Materials placed front fl.to It. blue tight sand and gravel w/water 80 155 r-tt Surface Seal: ® Yes 0 No To what depth?20 ft. light brown hard pan 155 270 i Material used in seal seatoaltt light brown hard pan w/water 270 275 Did any strata contain unusable water' 0 Yes 0 No reddish brown conglomerant 275 320 o Type of water? Depth of strata Red Clay 320 370 0Method ofxalingstmtaoft _ light brown hard pan 370 440 PUMP: Manufacturer's Name Grandfos silt bound sand&gravel w/water 440 475 4 Type:sub U.P. 3 - sand&gravel w/water 475 476 1 WATER LEVELS: Land-surface elevation above mean sea level ft. Grey Clay 476 ? 4C' Static level 434 ft.below topofwcll mac 4/21/2018 E Artesian pr pressure lbs.per square inch Date o Artesian soarer is controlled by (cap,robe,etc.) 3 WELL TESTS: Drawdown,s amount water level a lowered below static level pWas a pump test made? III Yes 0 No If yes,by whom?Davis --- 2 Yield: 15 aallmin.with 443 fl.drawdown Mier 1 des. n I Yield: gal/min.with It Mawdown after hrs. Yield: ,al/min.with_f.drawdown atter Ion. Recovery data(time taken a.'-zero when pump turned off)(artier level mrasunvd from O IL well top to eater level) ,S Time Water Level Tina Water Level Time Wata Level - --- --- ---— — 0 ran 443 3min 434 t 1 1 437 2 435 a 0. ai Date often 4/21/2018 4 ---- .2 Basler test gal/min.with_ft drawdown alln_hrs. I- Airiest gal.:min.with stem set at ft.fur hrs. Artesian flow gp.nt. Date ---- • Temperature of water Was a chemical analysis etude 0 Yes ® No 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 DrillertEnginetz:Trainee Signature ��,` Address 340 NE Davis Farm Rd Driller or trainee License No.3142 City,State.Zip Belfair,Wa 98528 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. DAVISDI110OA Date 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 ntoy call Washington Relay Service at 711. Persons with speech disability may call 77Y at 877-833-6341. 26276 Twelve Trees Ln NW Ste.0 SPECTRA Laboratories - Kitsap Poulsbo,WA Wherr experience 7a9aNcrs 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM • Dale Sams*Collected Time Sample J - County Collected Monti Yew Type of Water System(died(only one box) ❑Group A ❑Group B tLa(x.'lter_ Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# /��p��/ (� System Name: 3170 NE .�j cis rCr --- awA i ( Contact Person: Day Phone: Cell Phone Emai: Eve.Phone: Send results to:(Prtd SI name,adtea9 and z1p code co MO allow foe elecaonlc coPY c results) - • j_LLO SAMPLE INFORMATION Sample collected by(name): -'1 Specific location where sampl cofected: Special instructions a comments: wt\` Type of Sample(check only one box) 1.❑Routine Distribution Sample(AlP) 2.❑ Repeat Sample(A!P) (from distnbuton system after unsat.routine) Chlorinated Yes ❑ No❑ Unsatisfactory routine lab number Chlorine Residual:Total___Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: I S I 1 I I I Chlorinated:Yes No ❑Triggered(AR) Chlorine Residual:Total Free____ ❑Assessment(A/P) 4.Surface or GWI Raw Source Water Sample(Enumeration) S ❑ E.cot ❑Fecal Filtered Yea__ No _ J 5.EA,Sample Collected for Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ,atisfactory ❑E.coli present ❑E.cot absent Bacterial Density Results:Total Cotiform._ _mpn/100m1.E.coi __mpn/100m1. Fecal Coliform _ cfu/100m1. HPC_ Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑_ --- Lab Reference Number DL�I �L d 13°p / Receipt Tp C` Method SM922381• COUNT!SM9712D Fitt �'['� Dahl 1 9/��w/9A��/ nnnprti 4 N d+or+r lea a.uea of vm+on or aarwee 1 LL7 1 J 2824 Dt l I V 2024 Mn eo disused Ml'at WVd C a&dosueae.r M99N Nnded ruipad h wdsued ltreu I..e.owd an rAW SW piton noth I rpm*Moe*a MMG/79414i NO d.e«7 ex mcol DOH LabSample# , t1.«r..l.r.kde«hc r.ilmrs ins twoV I yea.1 0�0 _10�Cl i+reu«.a dn.pn.e«a e�rsus re..�r ta.ew+ad .mer r9Pad sr sr.drkdea.aw DON Form 031.319(Oa.e&17) 1 Spectra Labs - Kitsap, LLC (Poulsbo) J ` SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C ...Where experience natters 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 2093477 MASON CO WA 06/01/2018 11.16 AM NOTCE TRIPLETT M114433 Roc Fe. 74 00 Pa es. 1 1111111 I I I III II I I III 11I I I 111111I 11111 III 11n11 I Iiii dill KI I II I1 lull I II I!I I I1 II11 Return To: Debra Triplett,PO Box 556,Seabeck Wa 98380 John Degarimore,C/O 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 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 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 J 20 a , Deb0. L v -•`T r�(�r \P* .- sonally appeared befor me,who is known to be ner of the above instrument,and acknol)vledged that h=(0)they)signed it. GIVEN under my hand and official seal the day and year last above wri . _ t \��\�NA‘li tlt Notary Publi in and for the State of W hington ribnit Q ' i ��,1E GI/�q f f�// residing at L\vttrcl gl E , M or Q5` `ystON .0 /,� My commission expires: L'�J'�Q 1�D 20 4 014 a �� . / f �O t' . y ?�� i 5 V rA �2 • A ,11/J;7•29 0�4 jA. - 2093478 MASON CO WA 06/01/2018 11,16 AM NOTCE TRIPLETT #114433 Rec Fee. $74.00 Pages. 1 I IIIIIII II III II!IIII hull IIIIN Illl llll llll IiIII IIIIIII 111111111111111 II! Return To: Debra Triplett,PO Box 556,Seebeck Wa 98380 John Degarimore,C/O 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 Sedion 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 TR!PLETT/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 s stem (has/has not) been granted one or more waivers from specific provisions of the re. ons. ignature , Signature State of Washington County of Mason I,(h ve undersigned , a Notary Public in and for tie abo n med County and State,do hereby certify that on this 11 day of 20 tr.) , 1��t1'1 Q. 1 iwl f�Q 1'ti personally appeared before wn me,who is kno to be signer of the above instrument,and acknowledged teat he(she)( y)signed it. GIVEN under my hand and official seal the day and year last above written Notary Public Notary Pub t an f r h ate o Washington State of Washing,ton residing at My commission expires JENNIFER K. 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