HomeMy WebLinkAboutUntitled (2964) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
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
WEL2024-00001
XXX SE Walker Park Rd
320215009014
The 2-party water system, Walker Park#2 (320215009014 to 320215009012/320215009011), 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. ^ (4...,
COMMUNITY SERVICES Amount ei
� Receiv B, "
Building,Planning,Environmental Health Community Health _
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L 2 6 Z.L, - 0 C) l
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICAt ( PHONE-23-3 .3%--((C`? '
MAILING A-D�DR?S-STREEP/T,,CI_Sei, r`t i 1` ( e t qr-
SITE ADDRESS-STREET,CITY,STATE,ZIP `/L f
qN /
PRIMARY P�RCEL NUMBER(WELL SITE) �4q
SECONDARY PARCEL NUMBER APPLICABLE) 5-6)2 ( BiZ / 32.( ` - eulcg-
,
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
,f New ❑Existing Wel1 ❑ Spring to g .[jam" 0 /�,-3( 11 fT c.
PROPOSED WATER SYSTEM NAME(REQUIRED) `1�
('`)!' tit 1et�K- i
PROJECT DES IPTION p
L el1 IA) -fit 13L7 (3 l.)Ii( pg �iS�•( 561ivY u Wy tts:
6 &c\ 3202 5ct— 6W l R va( i)v,e v 32,&1( -cv-C.)?0 I I .
DIRECTIONS TO SITE/CONDITIONS 1 T
674) S� 0WV �L \ I'Aj L14 �. I M7,A. I Y' (,)A,
A 'key Pi/1c—I4ie 1 /-t° -S 07v fy.4 r y/bSS 5 ° - pn/L.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
4,,_ /4-i- dri-1 %,,,, ,
\-10 '')W3 1
BAN "
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BY
I
Submittals Checklist: (these additional items will be required for approval)
4 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
r o
_________ _____w Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
/❑ ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
J ❑ ❑ 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? ,g
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
® ❑ ❑ Is the well cap satisfactory?
pi ❑ ❑ Screened and vented? ,
❑ The well casing extends /6above level rounoncrete slab? (circle one)
Xi ❑ ❑ Is there evidence of a surface seal? La f-. t_ -,2-0 11 436
El Does the seal appear adequate? 1 1 Z 06(e l a
� u.+'1 . — 3.
❑ ❑ Is a variance necessary for well site approval? ri-051; VC
713
Comments 1 g ta lye.1/ 6 k IV
Pass ❑ Fail Inspector Date i f I LQl L/J Review Step 2: Two-Party Review:
YES NO NA
`% ❑ Water Well Report with adequate pump test on file? ifji4S f,wd j4f 'bfe+?
If NO, date of Capacity Test S Milt' Driller /0 5 4aL. Gl5 GPM .Z6
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test I/3/XZy
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZZ(J G(G
yl ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments /!1 (C CUB chci gfec ve 3/(Z 7202 L/ ; 11 Q"O)0/
cLa CPT
Approved ❑ Denied Reviewer z----�� Date VI172—a7,5
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
'Auarenusrgn ID:5B099CC6-0463-EE t b5925-A0456DDCB603
WATER WELL REPORT _:=_... W
' DEPARTMENT Or NoticeoflntentNo. E52628
-=:"li ECOLOGY
Unique Ecology Well ID Tag No.BPC713
Type of Work: 'it State of Washington
® Construction Site Well Name(if more than one well):
0 Decommission `--- Original installation NO1 No. Water Right Permit/Certificate No.
Proposed Use: 13 Domestic G Industrial ❑Municipal J Property Owner Name BRAD ROHR
❑Dewatcring 0 Irrigation 0 Test Well 0 Other Well Street Address0 WALKER PK RD
Construction Type: Method: CitySHELTON County MASON 1
0 New well 0 Alteration ❑Driven 0 Jetted 0 Cable Tool320215009014ASON K
❑Deepening 0 Other 0 Dug Bi Air- U Mud-Rotary Tax Parcel No.32Q2,ti5w5005 _
Dimensions: Diameter of boring 6 in.,
to76ft. \.Vasa variance approved for this well? ❑Yes ®No 01/30/24
Depth of completed well 76 ft.
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
® I 0 6 in. +1_5 76 .25 in. E I ❑ El I ❑ Il Location(see instructions on page 2): ®WWM or 0 EWM
❑ I ❑ in. in. Q I ❑ DID SW 1/4-1/4 of the SE /.;Section 21 Township 20N Range 3W
❑ I ❑ in. in. ❑ I ❑ ❑ 1 Q❑ I 0 in. in ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.20122
.
Longitude(Example:-120.12345)-123.06181
Perforations: ❑Yes 9 No Type of perforator used Driller's Log/Construction or Decommission Procedure
Perforated of perforationso Size of w ground surface byin. Formation:Describe by color,character,size of material and structure,and the kind and
from ft.to ft.below Bound nature of the material in each layer penetrated,with at least one entry fur each change of
Screens: Q Yes 0 No 0 K-Packer r,=> Depth ft. information. Use additional sheets if necessary.
Manufacturer's Name Material From To
Type Model No. BROWN CLAY,GRAVEL 0 35
Diameter in. Slot size in.from ft.to ft. GRAY SANDY CLAY 35 56
Diameter in. Slot size in.from ft to ft. 56 70
- GRAY SANDY CLAY
Sand/Filter pack:0 Yes ®No Size of pack material SAND&GRAVEL 70 76
Materials placed from ft.to ft.
Surface Seal: il3 Yes 7 No To what depth?18+ ft.
Material used in seal BENTONITE
Did any strata contain unusable water? 0 Yes lg 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: Laud-surface elevation above mean sea level 50 ft.
Stick-up of top of well casing+1.5 ft.above ground surface
Static water level 8.5 ft below top of well casing Date 5/9123
Artesian pressure— tbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? 3'i No 0 Yes by whom?
Yield gpm with ft.drawdown after hrs.
Yield gpm with ft.drawdown after lies.
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.
Air test g0 gpm with stem set at 74 ft.for 1 hrs. Date 519/2
Artesian flow_gpm
Temperature of water 'F Was a chemical analysis made? 0 Yes 0 No Start Date 5/8/23 Completed Date 5/9/23
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 0 Trainee 0 PE Print Name DANIEL KING Drilling Company KINGS WATER WELLS
Address 409-23 REINKE RD
Signature '� City,State,Zip CENTRALIA WA
License No.2949 98531
IF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature R No.KINGSWW931QM Date
5/24/23
ECY Pesons with hearing loss can ca
OOvcou teell Washington 711 for Relay Service. Persons with speech disability can call 877-83-6�1 6b'7'.
Thurston County Environmental Health
2000 Lakeridge Dr. SW 6 Olympia,WA 98502
360 867-2631
THURSTON COUNTY
emsimmurrm
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
/ , Collected 4ton
hlontn Day Year
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: I7
Day Phone:( J) 36 ' s--?' Cell Phone:(' —)-
E-mail:j'? t4 y 21,(:,„„ Eve.Phone:4_--)
Send results t :(P' t tu I name,ad rs and zip code or email address) -
z7 ►,>fm1 4 — r — —
SAMPLE INFORMATION
Samplected�y( me):,
15/>.,l) r�k4r
Specific location or d ess where sample collected: Special instructions or comments:
32 2 -- U�- OTC)"I
,E.:. -47,-2c,xis-
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.colt-GWR(AP)
❑Fecal-Surface,GWI,spnngs(nu erabm) Unsatisfactory routine lab number:
Filtered:Yes_No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S 1
, Sample Collected for Information Only
Investigative Construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULT LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Natisfactory
oliform detected
. ❑E.coli present ❑E.colt absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100ml. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code*tv19223B ❑SM 9222D Date and Time Received:
❑SM 9215E ❑Enterolert® I --3 • 24- Di 3 t)
1 Date and Time Analyzed: j • -j • 2 Date Report4d::±2.'I-'4
Sample Number(DOH number plus five dgits Lab Use Only:
DOH�r,T/331i3m,5 G1116) 3\ I. L.{
2206161 MASON CO WA
01/02/2024 03.53 PM NOTCE
ROHR REAL ESTATE #193896 Rec Fee. $304 50 Page; 2
Ell In DI III.IIIIIII IIIIII In I I 111111111111311111
Return To
2e)-2.7 i1Jm i ktrPq.rIW,
Gr.l i/di- grcy
Grantor(s): (1) ZI-Nr— P ,/ -7_5( LI C, (2)
Grantee(s): (1) PUBLIC L(� �,��J JJ
Legal Description (1) ,etikei Rik-` gL�ci l� F > I- -i' 5 f i3c.
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 5 2- 0 7-- ( - .c O - 0 6, 1 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 2. C 2- I - S- 6 - 0C1 01 2.
Tax Parcel: (Connection 2) '3 2- 0 ' ( - 5-C./ - 0 0 I (
The system owner is responsible for1 keeping this s stem in compliance.
The name of the water system is: W�1 ( ice (�fi/Nl i Z
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 I day of PPLPrw1/7-<,- , 20 23.
Signature of Grantor(s):
(1) - , (2)
Page 1 of 2
I
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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 12 day of 'Q2.c elh-er , 202.3 , '16.fo,a\zul 12o1r, Q5 (Mi''i1°�
n P Q,ohr 1Kp1 E6 tk f, L..L•C personally appeared before me, ho 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.
��auullluu,,, Notary Public in and for the State of Washington,
aON ER Buret•"''% residing at �
.• SM N T ��i�
QQc�•s„e �,2 09• My commission expires: Oln`2 4(ZoZ _.
• e NOTAgy v,•
•• '°UBLIC
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Page 2 of 2
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