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MASON COUNTY 415 N 6TH STREET,SHELTON, ,E 98584
SHELTON:360-427-9679670 EXT 400
L BELFAIR:360-275-4467, EXT 400
` fr 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
WEL2024-00003
XXX SE Walker Park Rd
320215009014
The 2-party water system, Walker Park#1 (320215009014 to 320215009014/320215009017), 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
,, gr"Al! MASON COUNTY NTY Date Received
COMMUNITY SERVICES AmountR wed. S , Recei ty
• Building,Planning,Environmental Health,Community Health 415 N.6`"Street,(Bldg 8)—Shelton,WA 98584 W E L a 0 - 4.` 0600.
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANFrq? Fov'J PHONE
2,s3-39,=9s7.1
MAILING ADDRESS=ST1)4.1I(��/ _W- '. q� /y
ki3O
SITE ADDREP
SS-SSTREET,CITY,STATE,ZIP�) /���` OY_ jA
PRIMARY PARCEL NUMBER(WELL SITE) •1-164/7
721:) 1 — - C�9o1 `f Rc
Fi��
SECONDARY PARCEL NUMBE (IF APPLICABLE)
3202i — .'U — 090 r 7 320-2_ _So - o10 1 it
WATER SOURCE g SOURC TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
New ❑ Existing XWell ❑ Spring 0, ,.e, 0.31 A{,
PROPOSED T STEM1�.�ar LEOUIRED)I / '`
PROJECT'"��(E SCRION �Ll//�I 'Ai: f V� VrJ�-�' ` / VL.nV lf'Y"ttCf' i (�✓t'� �,(�1il^,
6 CV 37o�-G— -- ��/70��(( c 1 .4 6 i 3Z)2.( —sV—O 0( 7. �w
DIRECTIONS TO SITE/CONDITIONS �/
1 w,�y - 1 o Sf- c)✓ - / cJi%,t- `� bA Frain �;;ik (.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
V
,. Li(
4,,,,,
JAN 02 2023 '
U
By
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Submittals Checklist: (these additional items will be required for approval)
1 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)
4
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: nn '/
— IZ? fD 51= LA(:cil fu i'
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
I ❑ ❑ Are there roads within the 100 foo radius of the water source? If so, is road private, County or State.
What is distance to ROW? > Z
K] ❑ LI Does the ground slope away from the water source site? (show slope on plot plan)
Xl] ❑ ❑ Is the well cap satisfactory?
kn ❑ ❑ Screened and vented? f / I.'
❑ The well casing extends G (/ above level iiroun• /concrete slab? (circle one)
[ J ❑ ❑ Is there evidence of a surface seal? Lk r : Lg, zo as 7o
0 ❑ ❑ Does the seal appear adequate? L(/►1 : -1 Z j.U61 SG6S
❑ i 1 ❑ Is a variance necessary for well site approval? 05 , ppG It(VV
Comments pi Iv tveo 3PG .13
VI ' to wMl Pc 7-6
Pass ❑ Fail Inspector /2--------
Date V 3/,) N y
Review Step 2: Two-Party Review:
`Y S NO NA .��."
f7C1 ElWater Well Report with adequate pump test on file? s two 904 *fief(
TTT"` If NO, date of Capacity Test Sy(Q( 203 Driller $ L,14e'rtit(is GPM 200
ligl ❑ El Received Satisfactory Bacteriological Analysis? Date of t st 1 /50 0 7(
cg ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z ZO 6(ro0
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments lll"l CIrcoitieCtorif °�— l �3 � Z('� ('V a l �
ye
Approved ❑ Denied Reviewer Date (70211,
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
Authsotis,gn ID:5Bt199CC 5-D4 B3-EE 11-8925-&0456DDCBBD3
WATER WELL REPORT DEPARTMENT O Notice oflntentNo.WE52629
. ECOLOGY LOGY Unique Ecology Well ID Tag No.BPC714
Type of Work:
State of Washington
g Construction Site Well Name(if more than one well):
O Decommission Original installation NOl No. Water Right Permit/Certificate No.
Proposed Use: ffa Domestic 0 Industrial 0 Municipal Property Owner Name BRAD ROHR
0 Dewatcring 0 Irrigation 0 Test Well 0 Other Well Street Address0 WALKER PK RD
Construction Type: Method:
®New well 0 Alteration G Driven 0 Jetted 0 Cable Tool City SHELTON CountyMASON ,,"
0 Deepening 0 Other G Dug E Air- 0 Mud-Rotary Tax Parcel No_32031-5009u05 320215009014 Dr 01/30/24
Dimensions: Diameter of boring 6 in.,to 76 ft. Was a variance approved for this well? 0 Yes ®No '✓
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
CO i 0 6 in. +1.5 76 .25 in. OR 1 0 El I ❑ Location(see instructions on page 2): 8i WWM or 0 EWM
❑ 1 0 in. — — in. 0 I ❑ 0 I 0 SW 'A-1/4 of the SE /.;Section 21 Township 20N Range 3W
❑ I ❑ in. in. ❑ I ❑ ❑ 1 ❑❑ 1 ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.20133
•
Longitude(Example:-120.12345)-I23.06183
Perforations: 0 Yes rid No Type of perforator used Driller's Log/Construction or Decommission Procedure
Perforated• of edffrations Size of w ground surface in.by in. Formation:Describe by color,character,size of material and structure,and the kind and
from ft.to ft.below ground nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes i No 0 K-Packer r--) Depth ft information. Use additional sheets if necessary.
Manufacturer's Name Material From To _,�
—
_
Type Model No. FILL 0 2
Diameter in. Slot size in.from ft.to ft. BROWN CLAY,GRAVEL 2 30
Diameter in. Slot sire in.from ft.to ft. 30 40
GRAY SANDY CLAY
Sand/Filter pack:0 Yes ®No Size of pack material GRAY CLAY,SOME GRAVEL 40 55
Materials placed from ft.to ft. GRAY CLAY,SILTY SAND 55 65
Surface Seal: E Yes 0 No To what depth?18+ ft. SAND&GRAVEL 65 76
Material used in seal BENTONITE
Did any strata contain unusable water? 0 Yes 0 No
Type of water? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name Type:
N.P. Pump intake depth: ft. Designed flow rate: gpm
r
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 8 ft.below top of well easing Date 5/10/23 _
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cop,valve,etc.)
Well Tests:
Was a pumping test performed? 0 No 0 Yes c—', 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 I
—
Date of pumping test_ '
Bailer tut _Wm with ft.drawdown after hrs.
Air test 20 gpm with stem set at 74 ft.for 1 hrs. —Date 5/10/23
Artesian flow gpm Completed Date 5/10/23 I
Temperature of water °F Was a chemical analysis made? 0 Yes ®No Start Date 5/9i23 P
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 0 Trainee 0 ' Print ame DANIEL KING Drilling Company KINGS WATER WELLS
Signature _ Address 409-23 REINKE RD
City,State,Zip CENTRALIA WA
License No.2 98531
IF TRAINEE:Sponsor's License No. Contractor's
g
Sponsor's Signature Re istration No.KINGSWW931QM Date
5/24/23
ECY 050-1-20(Rev l 1/18) If you need this document in an alternate forma,pk.s,..i.ull the l iuts, ILsaurcea P og.uu,at 360 407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-S33-6341.
Thurston County Environmental Health
_ 2000 Lakeridge Dr.SW t Olympia,WA 98502
_ -- 360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected //�
Month Day Year
Type of Water System(check only one box) private Household
❑Group A ❑Group B 0 Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:Ira) 1.,, -,
1
Day Phone:('tee 3) 3 (7c 5771 Cell Phono<_---)
E-mail: 1j�� � f- s� .n�i(, �
,, e.Phone: —)
J
Send results to:(Prir2411 name,address u zip code or email address)
SAMPLE INFORMATION
Sample collected by(name):
',aA ti_i_.,_ Li.7"---
pecific location or address where sample collected: Special instructions or comments:
gfte( 32-4)?.( $ `-'--OcT& (k'
PIE 52 l
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.coil—GWR(A/P)
❑Fecal—Surface,Gwl,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No _
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / i
S
?INSample Collected for Information Only
Investigative Construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and atisfactory
❑E.coli present ❑E.coli absent
'Jo Eoliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coli 1100m1.
Fecal Coliform /100m1 Enterococci 1100 ml.
Method Code: *9223B ❑SM 9222D Date and Time Received❑SM 9215B ❑Enterolert® 1"3 Z Cy 3v
Date and Time Analyzed: 1 - 7 . L' - Dale Reported:I.-,-1- 2
Sample Number(DOH number plus five Cig:ts) Lab Use Only:
0 8 0
DOH Form e331.319(reused 01/16) .� I C{ `C t-1
1 rrw l -t
2206160 MASON CO WA
01/02/2024 03 53 PM NOTCE
ROHR REAL ESTATE #193896 Rec Fee. $304.50 Pages 2
11111111 IIIll1 II I I III I III I!IIII IVI IIII III VIII I1111 IIII II!
Return To
Vr
2)27 will OA_(d,
> mirky
Grantor(s): (1) R `W ?___„1 1 `-LL2)
Grantee(s): (1) PUBLIC Legal Description (1) V"A J IK-e✓ Dq e •/40
L 1 - -S 561236
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3_ 2 C)2- 1 _, co - 09 0 14
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) 7 2 2 2 L - 5— 0 - 0 9 U ( 4
Tax Parcel: (Connection 2) 7 2 G - l
The system owner is responsible for keeping this system in compliance.
The name of the water system is: IA141 !2( i ?i'- 0- I
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 day of QPCevh , 20 2-.
Signature of Gra or s :
(1 , (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 12_ day of D2C reel , 20 2.3 , Uracile� Rohr, Q5
(yerce( pc 12.c*hr 12 o Esitcfp. LL•C.. personally appear d 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,
��BUR . i' , 1
0 �M.... ��� residing at Ole)p
g��.oz°'z '9••, My commission expires: QU2y\202LP
g N0TARY
PUBOC
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Page 2 of 2
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