HomeMy WebLinkAboutWEL2024-00020 - WEL Application, Design, Letter - 3/25/2024 MASON COUNTY 415N6 SHELTON: ,BHE7-957 ,EXT 4
HSTREE HEL ON, A9858
40 BELFAIR:360.275-4467,EXT400
Public Health & Human Services ELMA 360482-5269,EXT400
FAX 27-7787
RONNY CLARK
P.O. Box 3009
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2024-00020
1031 SE Arcadia Rd
320282200020
3/28/2024
The 2-party water system, Clarcadia Water System (320282200020/320282200010), 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.
Condition: No development may occur in the areas logged under FPA# 2420872, issued by the WA
Department of Natural Resources. This development moratorium is effective on the date of issuance,
0 3/2 212 0 1 9, until the 6-year development moratorium expires on 03/2212025. Any development or
construction for this two-party well water system must be in accordance with the moratorium resulting
from FPA# 2420872 and RCW 76.09.
If you have any questions, please contact me at 360-427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincerely,
/0/Z___
David Anderson
Environmental Health Specialist
Mason County Environmental Health
MASONCOMM COUNTY
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TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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Site Plan: (may also be attached)
Ipropwry b hd-des,sm,dureE,well sba w/1pp'radius,dnvs ",weds,ii'6i sewer Cumporents and hoes,eassmenb,
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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 Formed and available for public view on the Mason County Web she. Reused: 10J 2021
Page 3 of 2
Review Step 1: Well Site Inspection: V wun 5 of - ';,Jr�rl ry5�I.) 64Y COVI I"a fa.? Pf�t/YssSGj
YES NO NA 'Lti APS1t! $' gv0.y -1" ref �p,?f
rr 'AY/l� 4 Q
sf-I ❑ ❑ 00
Evidence of existing sources of contaminationY1�y within 100 foot radius of water source?
r (drainfields,tanks,buildings;indicate distance on plot plan)
❑ ❑ Are there roads within a%100 too{ dius of the water source? If so,is road 'vat Coun or Slate.
What is distance to ROW?�`_� lY
r,,,� ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
•`+ ^M S6N Y 00 Of P6u L �Ih hAli lt✓
❑ Is the well cap satisfactory? 4Ll �[Vp L�M� e�9 � � k
❑ ❑ Screened and vented? EAU t f 'f •"11,111000 6 P ►tp{G /i7RC fbn
❑ The well casing extends $ above level ground! ncrete sla (c�le one) r
❑ ❑ Is there evidence of a surface seal? Lei 4pIft 11L
XT ❑ ❑ Does the seal appear adequate? II ,,��
Lon
❑ [ ❑ Is a variance necessary for well site approval? ` -4 "
/� ,�a �II� ` '_ � sec rf S �)
Comments I�IU�LNUIP. / ._ pn,c
Pass Faii Inspector - �1 ujy/ a7—
Review Step 2: Two-Party Review:
Y S NO NA
❑ ❑ Water Well Report with adequate pump test on file? ArCifle" Pro7ol un j2.tzF/14t7 tr/ 30(/A fs1'
9 6601
If NO,date of Capacity Test MIZOW Driller OIII 4' 0/11 GplN Jg414 fir
❑ El Received Satisfactory Sacteriological Analysis? Date of tes: /zQ (1y1p 6w)
E) El Received signed, Notarized,and Recorded Notice? AFN 7.M R ry f If
gr ❑ ❑ System
�appears
vaideequatte to serve
22 single-family residences based on information provided?
Comments 411 e i°G G►r�d—` n
G!!R
tS Approved ❑ Denied Reviewer Date r71zoZ-cl,
Findings In do,review rapes!observed conditions as 1h v enured on the day ofihe site insp,,mon. No claim is made.eryress
or implied of lhe,fvmre sucwss or failure nfthis sys/am. WeY site approval does not constimie water.y.v em approvvl. Water
Sysem approve!is a two-pare process_
All proposed connections to new well,ass subject to venter adequacy requirement,at time afbuikling permit per MCC 6.68
Water wage restrictions and additional fees may apple to all new wells drilled after,Amatty 10, 1018 per ESSR 6091.
this form may be scanned and available for public view an the Mason County Web site.
Revised: 10AM021
page 2 of 3
Dip.Rmmilp[PdcobdCODY wIN WATER WELL REPORT ADWnDm Na. ..--.......___..__
�w'y SYA7'e OF WABIDNGTON eamn No. ....
(t) OWNER: .�y�-Y l.s ��•.r 1�lM..A.in._ waat..._q_ ..._._V._' 11 ns�.�Y- 6.�.a.r._._..._.__—.__J
2) LOCATION OF WELL
�uarine u,e aat,aro[mm.dm or.obNVWon rorn.
3) PROPOSED USE D®.uc p/bdmtrul 0 mYmd"❑ (10) WELL LOG:
urltldnn ❑ TM Well ❑ MN p ry�tthlekvu n/apuel(mbvne Ir�M klr�oM nnmumry%!M 111m.r41 In IMIt
-y N mm N.mna, sew at bse ev..ry/.ea h ckanp. D1 omaapn.
�4) TYPE OF WORM
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(6) WATER LEVELS.
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(9) WELL TESTS: b�y.�a
O W..Pump tet m.d.r Y.❑ _ DRILLMS STATEMENT,
C n ta: d ooc.wf 'h"enwaewo.N. en. WELL
was drilled under MY 1tu1a:IlMon and thle report is
.. true to the beet of MY knowledge and Leliet.
Romv.er a.. Rime .ken u uro wa® PDmD beme od) M..
N m.mm.a room eau top b m.r]sell - NAME {
Cqo.r t�P.1 Thar Wm.fAum T. Water rwv+1 � ...
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COOLWATER DRILLING, INC.
10921 HOLLY RD NW
BREMERTON, WA 98312
360-830-9005
COOLWDI941QM
-
CUSTOMERNAME: DATE 2-9-24
RON CLARK ___
CUSTOMER ADDRESS
1031 SE ARCIDA RD
TIME STATIC GVM _ TIME STATIC GPM
r 90
-- -- --
05 193 ( 14 120 1% _ 14
1.10 196 14 135 196 14
15 196 14 _ 150 1% 14
20 196 14 165 1% 14_
25 196 - 14 ISO 1% 14
30 196_._ 14 _ 205
45 ' 196 _ 14 _ 220 196 14
60 196 14 235 196 14
-._
75 � 1 14 245 _ 14
90 i 1%% 14 -----
----- -----
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RECOVERY STATIC REC RY STATIC
TIME_ --__ 196 TIME
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SAMPLE INFORMATION j
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AS USE ONLY s DRINKING WATER RESULTS -MUSE ONLY I
❑UnW.bclay id.ICd'iMm Preseni.nE ______-___ bcmry
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Grantor(s):
Grantee(s): (1)PUBLIC
Legal Description (1)TBL aG _52$ 7s R 3
r
r (Abbrewafed farm:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 3 U --7--7- _ o O O -6-
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
1(We)the undersigned grantor(s), certify that the water source located on the above-described
real estate unoer 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 t) 1 U 2 g -�Z_Q. 0 0 2 0
Tax Parcel: (Connection 2) 3 Z O 2 Qo -z Z-- O J O
The system owner is responsible for keeping this system in compliance.
The name of the water system is:
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 2s _day of M4--h , 20 Zy.
Signature rantor{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
719certif that on this Z�day of M a vr.k ,20�,
V1V1U C-(d,V K( personally appeared before me, who is known to be
signer of the abbve instrument, and acknowledged that he(she)(they si ned R.
GIVEN under my hand and official seal the da ar last a
```my TAN,—, Yi* re ry Public in and r the State of Washington,
X flcl �iva�t
�,�P:b!pngaj�i�y,. % mmission expires: ,r'—w - 7
s ;V
41/�Fr0Fr
Page 2 of 2
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