HomeMy WebLinkAboutUntitled (2962) MASON COUNTY 415 N 6TH STREET,SHELTON:360 SHELTON,
670,E E XT 98584
400
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BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
ROHR REAL ESTATE LLC
2027 WALKER PARK RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00002
XXX SE Walker Park Rd
320215009014
The 2-party water system, Walker Park#3 (320215009014 to 320215009010/320215009005), 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
r-
. ,
MASON COUNTY Date Received —^ —T�
COMMUNITY SERVICES AmountRe�eived G Received8
J ���
Building,Planning,Environ mental Health,Community I iealth
415 N.6'Street,(Bldg 8)—Shelton,WA 98584 W EL ' o Z,(4 , 0UQ0Z
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT '��J//'��,/� PHONE
MAILING AD S-STREET,CITY, 1.- ar3 -3 �-44
-ate w t'; 1ke,-- rev ."_ s t,
SITE ADDRESS-STREET,CITY,STATE,ZIP A
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PRIMARY PARCEL NUMBER(WELL SITE) 2024
SECONDARY PARCEL NUMBER(IF APPLICABLE)
-326Z/ - SZ'i O U (U / ?2j 21 — s - 6),c
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
New ❑Existing ygrWell CI Spring Cie qL_ C)..3 / j
PROPOSED WATER SYSTEM N ME(REQUIRED) `�
PRt�4/ I /e Vae- 3
T DESCRIPTION l
t J i/ wigsi-rT --7r L 71 5- w.'I( SeVve -1-1-1k) ne(= o 6•ik-
77o-2, - . - o G/() ei44 01,- ;a)z1 _so -oc?&Os
DIRECTIONS TO SITE/CONDITIONS Ace-Jik6t_
67 C.Ls+- 0ri 1/ 1,76 L�.,, 3 . C-(c . i r
�)M /�-rf iq✓1�- a �,',%1,c' ,? a.\ 1, 1,,h ,-„ a-, r,,,g_.
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Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements.etc...)
irr ii/ --- /
l of :
AN 0 2 2023 11
I
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 form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page lof2
Staff Use Only —
., ...=31,6 . ,,,: M:� sa, r nom,,,,—,W .n.. ,,,,,,_TN,:,:-.c,,.ns:... xa—_1..v�,,aa.=.. .
Review Step 1: Well Site Inspection:
YES NO NA 66 , to SE L..allq' ' "4
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
yf ❑ ❑ 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? 66'
►'I, ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
X ❑ ❑ Is the well cap satisfactory?
tr ❑ ❑ Screened and vented? A I i
❑ The well casing extends 2 �/ above level roun /concrete slab? (circle one)
`] El El Is there evidence of a surface seal? ef r - y F.2O (10 t_/
] ❑ ❑ Does the seal appear adequate? t G'j ► _ 113 d 6 t'k Y 7--
❑ ❑ Is a variance necessary for well site approval? TAG 6 Pc 71 5-
Comments I L -fa vet/ 6 Pc 7 f 11
Pass El Inspector Date 11 3 (/101'4,
Review Step 2: Two-Party Review:
YES NO NA
El Water Well Report with adequate pump test on file? lt'pH 10 t41
If NO, date of Capacity Test sl Ct'I`tt/7i,� Driller S the 10t &II GPM i 0
Bacteriological Analysis? Date of 1 0/?at(
[� ❑ El Received Satisfactory g Y
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 7-LO 6 f G Z,
X ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments MCe Co C e I/R z00z 'f- coo gat p
dAy par crmfl n .
(Approved ❑ Denied Reviewer Date 37/ 11 / W
Findings in this 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 19th, 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
il -v 7
AuthenIis1gn ID:56099CC6.0463-EE 11-8925.60456DDC6503
WATER WELL REPORT ^ DEPARTMENT OF Notice of Intent No.WE52630
ECOLOGY Unique Ecology Well ID Tag No.BPC715
Type of Work: State of Washington
O Construction Site Well Name(if more than one well):
O Decommission =' Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: 0 Domestic 0 Industrial ❑Municipal Property Owner Name BRAD ROHR
0 Dewatering 0 Irrigation ❑Test Well ❑Other
Well Street Address°WALKER PK RD
Construction Type: Method:
0 New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City SHELTON County MASON
❑Deepening ❑Other ❑Dug 3 Air- ❑Mud-Rotary Tax Parcel No.3202,1��S$D05 320215009014`DK
Dimensions: Diameter of boring 6 in.,to 78 ft. I\
Was a variance approved for this well? ❑Yes ®No
Depth of completed well 76 ft. 01/30/24
Construction Details: Wall If yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
O 1 0 6 in. +1_5 76 .25 in. El I 0 El I 0 Location(see instructions on page 2): ®WWM or 0 EWM
❑ 1 ❑ in. _ in. ❑ 1 ❑ ❑ 1 ❑n i D in. in. ❑ l ❑ ❑ I ❑
SW 1/4-1/4 of the SE 'h;Section 21 Township 20N Range 3W
❑ I ❑ in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.20124
Longitude(Example:-120.12345)-123.06193
Perforations: 0 Yes ®No Type of perforator used
No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure
Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and
_ nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes 2 No ❑K-Packer Depth ft. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No. FILL-ROCK 0 1
Diameter in. Slot size in.from ft.to ft.
Diameter in. Slot size in.from ft.to tt. BROWN CLAY,GRAVEL 1 30
GRAY SANDY CLAY 30 45
Sand/Filter pack:El Yes t&No Size of pack material GRAY CLAY,SILTY SAND 45 61
Materials placed from El.to ft. SAND&GRAVEL 61 76
Surface Seal: E Yes 0 No To what depth?18+ ft.
Material used in seal BENTONITE
Did any strata contain unusable water? 0 Yes Z No
Type of water? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name Type:
H.P. Pump intake depth: ft. Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level 50 ft.
Stick-up of top of well casing+1_5 ft.above ground surface
1 Static water level 9 ft.below top of well casing Date 5/10/23
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.) —
Well Tests:
Was a pumping test performed? ®No ❑Yes > by whom?
Yield gpm with ft.drawdown after hrs.
Yield gpm with ft.drawdown after his.
Yield gpm with_ft.drawdown after hrs.
Recovery data(time-rem when pump is turned off-water level measured from well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test —
Bailer test gpm with ft.drawdown after_hrs.
Air test 20 gpm with stem set at 74 R for 1 hrs. -Date 5/10/23
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes ®No Start Date 5/10/23 Completed Date 5/10/23
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 arc true to my best knowledge and belief.
El Driller 0 Trainee Cl PE P..ntt Name D L KING Drilling Company KINGS WATER WELLS _
Signature / aL�----[� J� Address 409-23 REINKE RD
City,State,Zip CENTRALIA WA
License No.2949 _
98531
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.KINGSWW931 QM Date
5/24/23
ECY 050-1-20(Rev 11/18) Ifyou need this document in at alternat. , .,�..•�...,Ilob,u,,,at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-533-634/.
Thurston County Environmental Health
2000 Lakeridge Dr. SW 1)Olympia,WA 98502
tiNkl,-Hak
360 867-2631
THURSTON COUNTYclammisacm
-
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
�7 i 2 i 2 Collected /y
Mpg AM ��VL� I n
Month Day Year �� �9 PH /`'(( 4
Type of Water System(check only one box) �'` ,Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: L 2 tr
Day Phone:(2 c3j) •3 c r, —4-1 5 Cell Phone:( ,./
E-mail: j.)&cerold,t�Z' 1^„yf1/, Eve.Phone:(4 z)''-L.
Se esults I/q(P lull,nam—e,`address and zip code or email address)
2e7 (r(
SAMPLE INFORMATION
Sample collected by(name): 7-7 / I
�4ecific location or address where sample collected: f Special instructions or comments:
re.e( 32.02,/-5n—O9°1Y
WE c263v
Type of Sample(must check only one box of=1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.col,-GWR(A/P)
❑Fecal-Surface.GWI,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(MP) Unsatisfactory routine collect date:
• DOther
, I
I . S
4�Sample Collected for Information Only
\Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
❑E.coli present ❑E.coli absent
o(,oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code:A'SM 9223B ❑SM 9222D Date and Time Received
❑SM 9215E ❑Enterolert® 1.--3 ' Z-- . ( )
Date and Time Analyzed: I - '3 2.'-( Dale Pedaled:t- 4-
Sample Number(DOH number plus eve doW) Lab Use Only:
0 8 0 CI
DOH FBr;#331 3l rrysed 01116) .2. 0 4(—/
• 2206162 MASON CO WA
01/02/2024 03 53 PM NOTCE
ROHR REAL ESTATE #193896 Rec Fee: $304 50 Pages 2
1 III1111 IIIIII II III I Rlllll Illl IIII III IIII IIIII I III IIIII IIIII III III
Return lTo
26Z7 1 ke/ P�k-,�1.
4L /4L �, g:s r
Grantor(s): (1) 1V 14I r� (2)
Grantee(s): (1) PUBLIC Legal Description (1) [j61 2/ ?A. k1 i!vc it-I-1 �1 _5 (0//
236
(Abbreviated orm:i.e. lot, block, plat section, township, range)
Assessor's Tax Parcel: (1) j 2 O ? I - - CJ 9 U / `f
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) .3 .2-- 0 ? l - 5-0 - 0 0 ( 0
Tax Parcel: (Connection 2) 73 -7--- O 2 ( - S 6 - t"? i7 0 5—
The system owner is responsible for keeping this system in compliance.
The name of the water system is: tNl! 4/Ike
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 1Z day of Oece. -7U�✓ , 20 23
Signature of Grantor(s):
( , (2)
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
certify that on this l2 day of 1) C.ernbeT , 20 23 , 3radley i ht, a5 tweMber
oc Qphr 140,1 F,S+a U_C. personally 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 written.
�a�►'"""' ���, Notary Public in and for the State of Washington,
0'3 MB**•'frz/ residing at 011'1 p 1c .•*gcVN Tnar 4P My commission expires: O to 12, +At• 1JZLo
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