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MASON COUNTY 415 N 6TH 0-427 967 , 98584
SHELTON: 360-427-9670, EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
P.
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
r, MASON COUNTY Date Received: �f
I. I COMMUNITY SERVICES
cA�w��t Recei d
�
W.
Building,Planning,Environmental Health,Community Health
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L 2 6 2_=4. - 0 0 l
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICA n PHONE
r id ( iv -Z.5-3--3'7t-4(C? .
MAILING 2RE1SS-STREET,CII Sko- Z(c i lr Z/ s 1 ,l of q1' i �� ,k'I
SITE ADDR SS-/STREET,CITY,STATE,ZIP �`/L-
PRIMARY PARCEL NUMBER(WELL SITE)
72421 S-0-- 0 1 1q Di�FD
SECONDARY PARCEL NUMBER(IF APPLICABLE)
202(— c"--0 —1()ct6IZ / •?o)Z( '-- 5V - v1'
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
ANew 0 Existing PE.Well 0 Spring C1 E AC- 6.S /03( AC.,
PROPOSED WATER SYSTEM NAME(REQUIRED)
Ind ti Lam"`' Q��r!� P
PROJECT DES PTION
1'1J /1 WI ` ..1 1' j3 L(7I 3 14)/ /1 i2f' 44 5142 I-6 st-.7i�`c' ---it),, tyt,CS
c) , e)Y\ 320� J��- 6 c>(Z q �>� 0 32& ( -Co-OWO/ I .
DIRECTIONS TO SITE/CONDITIONS a
1/4.‘. NCNA/L ' . . .1-;77,A_ 1,ef-1--- 61A,
L:� 91 1 kec- 2/1{1(-- t s ass s &. .
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
•
/4di-I ,,,,% .1 1
4, , 022a23
�p,N
BY
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
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
El ❑ ❑ 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? ,e
• ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
® ❑ ❑ Is the well cap satisfactory?
c( ❑ ❑ Screened and vented? J/ ,
0 The well casing extends r(7 above level rounoncrete slab? (circle one)
• ❑ ❑ Is there evidence of a surface seal? La t-. w?-., 2.o 11 436
,i ❑ ❑ Does the seal appear adequate? 123.
Z d 6 e yO
❑ LI Is a variance necessary for well site approval? Trciii; Pc 713
Comments / c{ hg 'lieu $PL 7l y
to Pass ❑ Fail Inspector Date I/111 jQl y
Review Step 2: Two-Party Review:
YES NO NA
/181 n ❑ Water Well Report with adequate pump test on file? i(ivS f,u/d 341 1O1QO
If NO, date of Capacity Test $ /f/l.iZ3 Driller 1045 kartilyedISI GPM ?6
•
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test I/3l X?41
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2.20 6(6 (
)6 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments ffl (C Cnie C c 3/I?/la 2 4 r Li p'cr5 0 '
cM CK
y
Approved ❑ Denied Reviewer4492 Date 1//1//zory
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
r
'Austennsign ID'50099CC8-D4B3-EE t l-S925-6O45BDDCBSD3
WATER WELL REPORT DEPARTMENT OF Notice of Intent No.WE52628
"..- --71 ECOLOGY Unique Ecology Well ID Tag No.BPC713
Type of Work: ;;;y State of Washington
E Construction Site Well Name(if more than one well):
0 Decommission Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use: Sgt Domestic ❑Industrial ❑Municipal Property Owner Name BRAD ROHR
❑Dewatcring 0 Irrigation 0 Test Well 0 Other_
Well Street Address°WALKER PK RD
Construction Type: Method:
®New well 0 Alteration CI Driven 0 Jetted 0 Cable Tool City SHELTON County MASON 1
❑Deepening ❑Other ❑Dug I$Air- 0 Mud-Rotary Tax Parcel No.32132,?5MSOU5 320215009014 ✓t 1
Dimensions: Diameter of boring 8 in.,to 76 ft. Was a variance approved for this well? 0 Yes i$No 01/30/24
Depth of completed well 76 ft.
If yes,what was the variance for?
Construction Details: Watt
Casing Liner Diameter Front To Thickness Steel PVC Welded Thread
® I 0 6 in. +1.5 76 .25 in. E I 0 I81 I 0 Location(see instructions on page 2): E WWM or 0 EWM
O I Q tn. — — tn. ❑ I ❑ CIO p I 0 in in O D D ❑ { O SW /,-%of the SE /.;Section 21 Township 20N Range 3W
.
O I 0 in. in. ❑ I ❑ DID Latitude(Example:47.12345)47.20122
Longitude(Example:-120.12345)-123.06181
Perforations: 0 Yes El No Type of perforator used
Driller's Log/Construction or Decommission Procedure
No.ofr tedffrtions Size of w ground s in.by in. Formation:Describe by color,character,size of material and;tincture,and the kind and
Perforated from ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes of No 0 K-Packer > 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.
Diameter in. Slot size in.from ft.to ft. GRAY SANDY CLAY 35 56
GRAY SANDY CLAY 56 70
Sand/Filter pack:0 Yes E No Size of pack material SAND&GRAVEL 70 76
Materials placed from ft.to ft.
i Surface Seal: I$Yes ❑No To what depth?18+ ft.
Material used in seal BENTONITE
Did any strata contain unusable water? 0 Yes El No
Type of water? Depth of strata I ` — I
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 lbs.per square inch Date '
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test performed? El No ❑Yes = by whom?
Yield gpm with_ft.drawdown after hrs.
Yield gpm with ft.drawdown after hrs.
Yield tom 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 ;Ton with ft.drawdown after`lus.
Air test ?0 gpm with stem set at 74 ft.for 1 hrs. Date 5/8/23
Artesian flow_gpm
Temperature of water °F Was a chemical analysis made? 0 Yes ®No Start Date 5/8123 Completed Date 5/9/23
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 are true to my best knowledge and belief
E Driller CI Trainee 0 PE Print Name DANIEL KING Drilling Company KINGS WATER WELLS
Signature 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) If you need this document in an alternak ft...o t,vlcusL Lull the It are, Resou,,.e.,l'ogran,r,t 360-407-6872.
Persons with hearing loss can call 71l for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
Thurston County Environmental Health
2000 Lakeridge Dr. SW fl Olympia,WA 98502
•= 360 867-2631
THURSPON COUNTY
oncnomcuma
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
i 2 2� 3 Ald r� /1
ts Pfd
Monty 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:3 i �y
Day Phone:( 364 Z S"7 ( Cell Phone:("----)--
E-mail:j)�7 / �(- yy�)/,aye Eve.Phone:�—)
Send results t :(P' t fu I name,adg and zip code or email address)
- -
SAMPLE INFORMATION
Samplex#ected y( -me):
l>_l A t
Specific location or dress where sample collected: Special instructions or comments:
32t)Z -- u•- G) `F
wE4 rP2
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(A/P)
❑Fecal—Surface.GWI.springs(nu-era:wn) Unsatisfactory routine lab number:
Filtered:Yes No
Li Assessment Monitoring(AID) Unsatisfactory routine collect date:
❑Other / /
S
4 Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULT LAB USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
oliform detected
❑E.coli present ElE.coli absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli /100m1.
Fecal Coliforrn /100m1 Enterococci /100yy ml.
Method CodeM 9223E ❑SM 9222D Date and Time Received:OL,�
❑SM 9215E ❑Enterolert® I •"3 - 2-1- 012j)
Date and Time Analyzed: I - 3 2,,U Date Report4d: --2.t'14)--
Sample Number(DOH number plus five dgis? Lab Use Only:
DONE rrpr331i33;(reised01r16) '3\ C:1''I.c L`
il.r
2206161 MASON CO WA
01/02/2024 03.53 PM NOTCE
ROHR REAL ESTATE #193896 Rec Fee $304.50 Pages 2
I►liii IIIIII III IIII IIII!II IIii IIII IIII IIIII IIIII III III III!III IIIII IIII IIII
Return To
2e)27 i,Jei 1 ker-Pellk=led,
Grantor(s): (1) -4L- Pee./ �5- LLL, (2)
Grantee(s): (1) PUBLIC If1 �Legal Description (1) Wei !v� ,_ ku, 1 1k ( L h I`-I -/ 5 ctf2 3c=
(Abbreviated form:i.e. lot, block, plat or section, township, range)
(A
Assessor's Tax Parcel: (1) 7 O .2- I - c O - C5 9 o I e-t.
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. ) 2 ( - 5® - 0 ' 0 1 2,
Tax Parcel: (Connection 2) - G '7-- 1 - G- 0 c, 0 f (
The system owner is responsible for keeping this s stem in compliance.
The name of the water system is: Liel I ker 0v4- It--2___
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 'aday of Y eL,,,,,,k'- , 20 23.
Signature of Grantor(s):
(1) - , (2)
4 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 12 day of •02.0 1Y)-e-T , 20 Z3 , i6ro he_ 12phr, as
p P Q.oh< �a1 ESi'a4e,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.
a00%11111w/4 Notary Public in and for the State of Washington,
`��`•\`\\?'_•Oft fN q�/ ''�•,�� residing at OkbM�10.
•IcVe• �•? Quiz 4,to9 • My commission expires: O �2 1Z .c1 Q7
s.
NOTggy .
PUBLIC
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