HomeMy WebLinkAboutUntitled (2963) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
«s. BELFAIR:360-275-4467,EXT 400
;; P 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
I
MASON COUNTY Date Received. — (/�^ —T?
1 l ` COMMUNITY SERVICES Amount g vea _ Received B
�
Building,Planninq,Environmental Health,Community Health
415 N.61h Street,(Bldg 8)—Shelton,WA 98584 W E L a. o ._,(-1 .... 0600Z
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
13(„( -\ -4
MAILING AD�E S—STREET,CITY,STATE,ZIP � `� � ��
2-0 -Z7 rA)L/ I( o- Pofl_ c -
SITE ADDR(jEESS—STREET,CITY,STATE,ZIP11 /^N
PRIMARY PARCEL NUMBER(WELL SITE) .uZ4
72-2_1 - S off'U,y R6ct-i. o
SECONDARY PARCEL NUMBER(IF APPLICABLE)
-52-621 - -- o c (o / ?2L21 - -- O4 CIO.S
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
New 0 Existing Jit Well 0 Spring G, et _.- ; / '' .9 PROPO ED WATER SYSTEM N ME(REQUIRED) 1
�„� 1 kez 1ari-- i3
PR JECT DESCRIPTION
113
>2G--2, (- . 'G- G G(C) q4 e 0n 37c)Z ( — Sc --01&OS-
DIREjI',TIONS TO SIT CONDITIONS /'J-
67v + Or- 41d1 'YID` �1i16 --1 . �ln ( '>1C7�O \
W-Pi
1 f 'i (�- a S-',' ,� a,-� /, 1,,E 07/14-.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
0
frr t/
II)
I ,
.iAM 00 2� 2023 ,1
� . \ . 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 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
66 ' to SE l,v.a/gcr feet (
4.
❑ ❑ 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.
What is distance to ROW? 6t
►_I, ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
cYr ❑ ❑ Is the well cap satisfactory?
,T ❑ ❑ Screened and vented? /� t 4
❑ The well casing extends 2 V above level roun /concrete slab? (circle one)
Z ❑ ❑ Is there evidence of a surface seal? c(f-_ 4120 (7- f c/
l�J ❑ ❑ Does the seal appear adequate? t Chl ! _ 1 Z 3 17 6/k Y 7 7"
❑ Ez ❑ Is a variance necessary for well site approval? Tc1 Q pc_ 71>
J
Comments l -iv 140 B pc 70
Pass ❑ Fail Inspector97 Date 11 3 (POlt-t,
Review Step 2: Two-Party Review:
YES NO NA
" ❑ Water Well Report with adequate pump test on file? 1100 5d I 14 kil
If NO, date of Capacity Test Motto-1,3 Driller vet 1 W GPM 'Z 0
/ tf
Received SatisfactoryBacteriological Analysis? Date of� i/1 t�l
❑ ❑ 9
Ai ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z.to 6 f G 1,
X ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments MCC CV-Ci C7 e 1/f zlzcZ LI: goo 9a l p-�
eity fir' collQ 4 .
(Approved ❑ Denied Reviewer A91 Date 3(1 ( W LLi
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 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
r
Authentisign rD:58099CCB-D4B3-EE11-8925-60458DDC88D3
WATER WELL REPORT m,. ,1 1 DEPARTMENT OF Notice of Intent No.WE52630
lawl ECOLOGY Unique Ecology Well ID Tag No.BPC715
Type of Work: State of Washington
S Construction Site Well Name(if more than one well):
❑ Decommission Original installation NOiNo. Water Right Permit/Certificate No.
Proposed Use: S Domestic 0 Industrial ❑Municipal Propetty Owner Name BRAD ROHR
Cl Dewalering ❑Irrigation 7 Test Well U Other
Well Street Address°WALKER PK RD
Construction Type: Method:
CitySHELTON County MASON
New well 0 Alteration ❑Driven ❑Jetted 0 Cable Tool r
0 Deepening ❑Other ❑Dug 2 Air- ❑Mud-Rotary Tax Parcel No.320215OC300b 320215009014 D
Dimensions: Diameter of boring 8 in.,to 78 ft. Was a variance approved for this well? CI Yes S No i
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
S I ❑ L.—in. ±Lij 76 .25 in. MID SID Location(see instructions on page 2): ®WWM or❑EWM
O I 0 in. _ _ in. ❑ I 0 OIC n I 0 ;n. in. ❑ I ❑ ❑ I ❑ SV6 /.%-' of the SE /.;Section 21 Township 20N Range 3W
❑ I ❑ in. in. o I ❑ DID Latitude(Example:47.12345)47.20124
Longitude(Example:-120.12345)-123.06193
Perforations: ❑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 0 No O 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 it BROWN CLAY,GRAVEL 1 30
GRAY SANDY CLAY 30 45
Sand/Filter pack:0 Yes S No Size of pack material GRAY CLAY,SILTY SAND 45 61
Materials placed from ft.to ft. SAND&GRAVEL 61 76
Surface Seal: B Yes Cl No To what depth?18+ ft.
Material used in seal BENTONITE
Did any strata contain unusable water? 0 Yes 0 No 1
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
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? I&No 0 Yes by whom?
Yield- gpm with ft.drawdown after hrs.
Yield gpm with_ft.drawdown after hrs.
Yield gpm with_ft.drawdown after hrs.
Recovery data(time=zero 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. 1
Air test 26 gpm with stem set at 74 ft.for 1 hrs. -Date 5/10/23
Artesian flow gpm
Temperature of water °F Was a chemical analysis made? 0 Yes S No Start Date 5/10/23 Completed Date 5/10/23
WELL CONSTRUCTION CERTIFICATION: 1 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❑Trainee O PE "nt Name DANI L KING Drilling Company KINGS WATER WELLS
Signature Address 409-23 REINKE RD
License No.2949 City,Statee,,Zip Zip CENTRALIA WA
98531
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.KINGSWW931 QM Date
5/24/23
ECY 050-I-20(Rev 11l18) If you need this document in an alternate j,,,,,at,l�..,.,ulEd,� f{'Lr.:, Rrsvu,,ca/n,g,o,,,at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call S77.833-6341.
Thurston County Environmental Health
er
2000 Lakeridge Dr.SW t Olympia,WA 98502
,r
360 867-2631
THUR.STON COUNTY
Dencurema
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
A 12 f 2 U Collected Am
/J/VJ�/� /�//�\
I ( ❑PM / `600 _
Month Day Year
Type of Water System(check only one box) rivate Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID»
System Name:
Contact Person: tar- 20Gr
Day Phone:(,5-3) 3(','- j S 9 Cell Phone:(4zn)v2,
E-mail: h* �a�d,� �J�„aj/, (M Eve.Phone:(4eAi _._
Setesults 1 (P' full name.,address and zip code or email address)
- �✓ —
SAMPLE INFORMATION
Sample collected by(name): -7 d ---7
I-Vie.4 Ko 14
(Jar_e(
cific location or address where sample collected: Special instructions or comments:
,z1---, --vO9C)1Y
WE c'?63 v
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.coli-GWR(AP)
❑Fecal-Surface.GWI.springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
0 Assessment Monitoring(A/P) Unsatisfactory routine collect date:
- ❑Other / /
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
0 oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC 0
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Coliform _ I100m1 Enterococci /100 ml.
Method Code:�'SM 92236 ❑SM 9222D Date and Time Received'
' ``❑SM 9215E 0 Enterolertr I.- ' 2-4-4 bLI 2Sv�
Dale and Time Analyzed: ( - -3 3-`1 Date Reported:t- t4- l'l V_.
Sample Number(DOH number plus five digits) Lab Use Only:
0 8
DOH Farr d331 31n(rewsed 01n6) '2.\C ' 4 L-1
2206162 MASON CO WA
01/02/2024 03 53 PM NOTCE
ROHR REAL ESTATE #193896 Rec Fee $304 50 Pages 2
H1111IIIIII 1111 IIII;IIIIIII II11111111111111 111111111111111110111
ri.11.1.1.1.111.1-Grantor(s):
rn To
z7 we,1(
Y.l4 w�4 cWS-8l
(1) ;;t"V `�� z,�( LL4(2)
ntee(s): (1) PUBLIC
Legal Description (1) J,61''2/ 1 k (�jk1 L )- /4-4 co/236
(Abbreviated orm:i.e. lot, block, plat rsection, township, range)
Assessor's Tax Parcel: (1) J 2 O ? I - s— 0 - C2 9 /
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 cc CSJ
Tax Parcel: (Connection 2) 7 O 2— ( - l - U 0 5
The system owner is responsible for keeping this system in compliance.
The name of the water system is: L/\, l k Pr� *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 12 day of OeCPoi '- , 20 2-3
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 (2 day of D2G2rnber- , 20 23 , rodley Y.ohc, v►5 (�e�ber
0C Q. . 12Z0,1 Fthak. LA-G 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.
\\�`���"""""'<<� Notary Public in and for the State of Washington,
0�� 8NRK4f
`;'�i,,�i residing at Qlievtek ..
QQ°�;"g2°,? � ;.. My commission expires: 0 to I2� 2c)2Co
.Q NOTARY •
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