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HomeMy WebLinkAboutUntitled (2969) MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 Via, BELFAIR:360-275-4467,EXT 400 -'r 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 Ir— MASON COUNTY Date Received 1 2....., .5) COMMUNITY SERVICES Amount !nod. , Receioed' y :.� S �� ;z` , Building,Planning,Environmental Health,Community Health 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 W E L a O '' ,Lk.__ op ccp3 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 i .<„ e�aaaa�m.wo�e..vamon'cxi..sss.�xvra�....,..v_. zr<.sw.v,e..,o�-:,.,......•..'-�•��..- _ TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT d Poor PHONE MAILING 2-ADDRESS E l;iCITY,�J i Can' V1/ ti ""' ete - , ,U SITE ADDRESS--SSTREETT,,CITY,/ STATE,ZIP f JL l,�/fQ,U�"^� 0 �A PRIMARY PARCEL NUMBER(WELL SITE) R N 16 202, SECON��CELANUMBE (R IF APPLICABLE) c 3 2L 2( - -CO - 09 0 1 7 32-C>-a. t 5-0 - o 1 o 1 t( WATER SOURCE • SOURC TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE New Existing Well 0 Spring vi g A- - 0,31 ,, PROPOS D 1� 1/f'�TE STEt�-Cj M — �'`F- UIR- l PROJECT DESCRIPTION t. QM( IA) , I P-7l# w': 1( ix of a 'iix_n Imo,-vcs: c�,� 1/1 )✓►,., a1v 32( 2 c 6 >n 32v2sof/( - - ( 017. �O1`i � DIRECTIONS TO SITE/CONDITIONS 4 k_ .1 61, 4-e,,z_ -(("( -eftt/tc +lAJL. eft-, Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) 9 1 , ii,..,i( 4(9( ., JAN O L 2023 Submittals Checklist: (these additional items will be required for approval) tli 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: — 52' fo S€ V 4/taw' q YES NO NA X ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ZI ❑ ❑ Are there roads within the 100 fooracius of the water source? If so, is road private, County or State. What is distance to ROW? > Z k] ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) Xj ❑ ❑ Is the well cap satisfactory? r ❑ ❑ Screened and vented? / / t` ❑ The well casing extends G U above level oroun• /concrete slab? (circle one) El ❑ Is there evidence of a surface seal? &41. : L0. 20 (2_3 N J ❑ El Does the seal appear adequate? L011 : —(2 j,U6 t$665- ❑ 0 El Is a variance necessary for well site approval? p pG 7 1L/ TGC� : V Comments ) Y` 'to (1 1)&G 7-13 VI ' 1-o . Ml PC 7-f$ Pass ❑ Fail Inspectore2- --- Date iV 311302 y Review Step 2: Two-Party Review: YES NO NA �r.� f�(vj ` E Water Well Report with adequate pump test on file? s rift''.944 *fief t If NO, date of Capacity Test 5/69 2 Driller .$ L' 4 1(15 GPM 20 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of t st 11500 0 7 1 Cl ❑ Received Signed, Notarized, and Recorded Notice? AFN ?2 0 640 0 El ❑ System appearsadequate to serve 2 single-family residences based on information provided?Comments m"l Cad.at .Ul'I!(.wI 3 l (I01('/ : YO0 rj a f pee" • Approved ❑ Denied Reviewer Date (/7/ze;?( f- 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 1 . Authei tisign ID:513499CC8-04B3-EE I1-5925-6045BDDCBBD3 WATER WELL REPORT 0 DEPARTMENT OF Notice of Intent No.WE52629 ECOLOGY Unique Ecology Well ID Tag No.BPC714 Type of Work: State of Washington ® Construction Site Well Name(if more than one well): ❑ Decommission r-'' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: R Domestic ❑Industrial 0 Municipal Property Owner Name BRAD ROHR 0 Dewatering 0 Irrigation 0 Test Well 0 Other Well Street Address0 WALKER PK RD Construction Type: Method: ®New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City SHELTON County MASON ❑Deepening 0 Other 0 Dug ®Air- 0 Mud-Rotary Tax Parcel No.324315C/09U05 320215009014rDK O'1-f30/24 Dimensions: Diameter of boring B in.,to 76 ft. Was a variance approved for this well? ❑Yes ®No Depth of completed well 76 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread i El I 0 6 _in. +1.5 76 .25 in. 0 I 0 ® I 0 Location(see instructions on page 2): lg WWM or 0 EWM ❑ I ❑ m. tn. ❑ I ❑ ❑ I ❑❑ I ❑ in. in. ❑ I ❑ ❑ SW 1/4-1/4of the SE %.;Section 21 Township 20N Range 3W • ❑ I ❑ in. _ _ in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.20133 Longitude(Example:-120.12345)-123.06183 Perforations: 0 Yes 6i 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 E No 0 K-Packer C 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 fl.to ft. Diameter in. Slot size in.from ft.to ft. BROWN CLAY,GRAVEL 2 30 GRAY SANDY CLAY 30 40 T GRAVEL 40 55 Sand/Filter pack:0 Yes ®No Size of pack material GRAY CLAY,SOME Materials placed from ft.to ft. GRAY CLAY,SILTY SAND 55 65 Surface Seal: ®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 Bi No Type of water'! Depth of strata Method of scaling 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 8 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? E No 0 Yes C by whom? Yield gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown aftcr 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 test gpm with ft.drawdown after hrs. Air test 20 gpm with stem sct at 74 ft.for 1 hrs. -Date 5/10/23 Artesian flow gpm Temperature of water °F Was a chemical analysis made? 0 Yes iE No Start Date 5/9/23 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 are true to my best knowledge and belief. Ig Driller❑Trainee 0 - Print ame DANIEL KING Drilling Company KINGS WATER WELLS Signature � Address 409-23 REINKE RD License No.29t!f�r City,State,Zip CENTRALIA WA 98531 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.KINGSWW931 QM Date 5/24/23 ECY 050-1-20(Rev l 1/18) If you need this document in an alternate fo,,,,at,ple..e t..,ll it, (Vat, R,.aovR.ea Proxrudrat 360 407-6372. Persons with hearing loss can call 71/for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Thurston County Environmental Health OF.— 2000 Lakeridge Dr.SW t Olympia,WA 98502 360 867-2631 THURSTON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected fias ,,^` Month Day Year c Type of Water System(check only one box) erivate Household ❑Group A ❑Group B ❑Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: f] 1.,,?Day Phone:(712S 3) -3 9 1 Cell Phone ( -} Email: Y Y . d tr,1 f .,r / e.Phonez4_) Send results to:(Pri ull name,address a}d'zip code or email address) -) q 4)65 ' q -sF-4f SAMPLE INFORMATION Sample collected by(name): fSpecific location or address where sample collected: Special instructions or comments: 'q!ze( 32.oz.( 57%--OS ('f 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 ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑Other / / S �4Sample Collected for Information Only ((/ Investigative Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑E.coh absent ryo Coliform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coii /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code: 'SM 92238 ❑SM 9222D Date and Time Receive ❑SM9215B ❑Enterolert© I-3-Z 04:12j. Date and Time Analyzed: l - 2 ' 2.---t- Date Reported:1-'-"'2`. ?l Sample Number(DOH number plus five digits) Lab Use Only: 0 DOH form 0331.319(revised 01/16) - C1 1 r !is ) -t • 2206160 MASON CO WA 01/02/2024 03 53 PM NOTCE ROHR REAL ESTATE #193896 Rec Fee $304.50 Pages 2 I II II IIIIII ill III!IIIIIII Ilii!III I II IILII IIIII IIIIIII III IIIII lUl III IIII ReturnTo kr- 262.7 (A,11l P�f ois-cfet Grantor(s): (1) i I �S Fag2) Grantee(s): (1) PUBLIC Legal Description (1) tAjoi 1 k ()qv' I. . Fa_ L i Li-/e„S 9 J2 3C) (Abbreviated form: i.e. lot, block, plat or section, township, range) (1 Assessor's Tax Parcel: ) 3 2 C)2 9 - I - .� C - 0 0 I q 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_ G 2 1 - - d 9 01 y Tax Parcel: (Connection 2) 7 ? G -2- -- �U- lV `a( i The system owner is responsible for keeping this system in compliance. The name of the water system is: LA kar f 1l/4-- 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 rZ day of Qecevii i/e7 , 20 2:3. Signature of Gra tor 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 12 day of 'Q,CeM\oer , 20 23 , arcdle Q5 [reviDef OF 120hr 12A0,1 �siz�FP. 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. BUA ����i Notary Public in and for the State of Washington, �.� O�MNrK'� ,�� residing at 01 �'lP« •gagg2•.2q-,9•• My commission expires: OLD 2y`202Co N0TARY ow.•� 267 //i/ 'WAS \‘‘` • Page 2 of 2 wFT. / . 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