HomeMy WebLinkAboutUntitled (2981) MASON COUNTY 415 N 6TH STREET,SHELTON, 98584
SHELTON:360-427-9670, EXT 400
BELFAIR:360-275-4467, EXT 400
ia. r
Public Health & Human Services ELMA:360 482 5269, ExT 400
FAX:360-427-7787
MARCINKO FRANK A & SUZE MARIE
5677 MINNIG LN NW
SEABECK, WA 98380
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00014
797 NE Blacksmith Dr
223107990663
The 2-party water system, Frog Hollow Water (223107990663/223107990661), 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 3 / 9 / a�a
COMMUNITY SERVICES Amofecerveil + Hecevea E;,
��% Building,Nanning Fnvwm mental Health,Carvmn gityHealfh ACt
415 N.6th Street,(Bldg 8) Shelton,WA 98584 W E L caw U - o 0o \Lk
Shelton: 360-427-9670 x400 Belfair:360-275.4467 x400 Elms:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
Frank andSuze Marie Marcinko 360-801-0147
MAILING ADDRESS-STREET,CITY,STATE,ZIP
5677 Minnig LN NW, Seabeck, WA 98380
SITE ADDRESS-STREET,CITY,STATE,ZIP
797 NE Blacksmith Dr, Belfair, WA 98528
PRIMARY PARCEL NUMBER(WELL SITE)
22310-79-90663
SECONDARY PARCEL NUMBER(IF APPLICABLE)
22310-79-90661
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
❑ New ti Existing M Well ❑ Spring 1.22 acres 1.35
PROPOSED WATER SYSTEM NAME(REQUIRED)
Frog Hollow Water
PROJECT DESCRIPTION
Newly drilled well to be shared between 2 lots in the same plat. Private access road and the cul-de-sac
access and utilities easement provides the avenue for the water line connection with sleeving under any driving surfaces
DIRECTIONS TO SITE/CONDITIONS
West on NE Bearcreek Dewatto Rd to a left on Blacksmith Dr, follow the
nice wide gravel road about a mile to the second left past NE Forge Ct, follow that driveway 100 yds to 797
Site Plan: (may also be attached)
(property boundaries,structures.well site w/100'radius,driveways, roads,septic/sewer components and lines, easements,etc ..)
i7t-fT54 .5qc'r o'er /
Submittals Checklist: (these additional items will be required for approval)
El Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
l Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
M Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
M 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 `CUYi Frees S✓r�.c
❑ (46 ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ ❑ 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?
"Alltlk‘k ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
Vjee
� ❑ Is the well cap satisfactory? U/2 ) Nair, r �G�O�e �tf �(1 �'
❑ ❑ Screened and vented?
_ -iit
❑ The well casing extends \)- ‘ 7 above level ground /concrete slab? (circle one)
[j ❑ ❑ Is there evidence of a surface seal?
[d ❑ ❑ Does the seal appear adequate?
❑ `p ❑ Is a variance necessary for well site approval?
Comments CdNaQ4t t ' a n/
3f f/Za ZY : A(tg (i le ce(i'i ofle#7 0(-e
Pass'Pass lit ail Inspector Date 3. - .. 7 - A-LE
Review Step 2: Two-Party Review:
YES NO NA 1600(at `{verul,
(r ❑ ❑ Water Well Report with adequate pump test on file? t/
/ v
If NO, date of Capacity Test 0/ ZQ Z3 Driller 4lPi C �} rt
6[ ( GPM V 4j
g ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ro 3 `/pen
g ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN _Z7_09
y ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
XApproved ❑ Denied Reviewer Date ! ( lit/e?j Y
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'r', 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
WATER WELL REPORT = Notice of Intent No.WE52723
--- L (�` t• )J ' Unique Ecology Well ID Tag No.BPS-260
i
Type of Work: -
Eg Construction Site Well Name(if more than one well):
❑ Decommission r ) Original installation NOI No. Water Right Permit/Certificate No.
Proposed Use. ®Domestic 0 Industrial O Municipal Property Owner Name Frank&Suze Marcinko
0 Dewalenng 0 irrigation ❑Test Well 0 Other
Well Street Address 797 NE Blacksmith Dr
Construction Type: Method:
®Ncs well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Belfair County Mason
0 Deepening 0 Other 0 Dug ®Air- 0 Mud-Rotary Tax Parcel No.22310-79-90663
ill Dimensions: Diameter of boring 6 in..to 177 ft
Was a variance approved for this well? D Yes ®No
Depth of completed well 176 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 +1.4 176 in ® I O ❑ 1 O Location(sec instructions on page 2): 0 W WM or 0 EWM
❑ I 0 in. in O i ❑ O I ❑ NW'A-%%of the NE'A;Section 10 Township23N Range2W
O I ❑ to _ in DID CIO
❑ I O in _ _ in. O I O O I O Latitude(Example.47.12345)47.50377
Longitude(Example:-120.12345)-122.91637
Perforations: 0 Yes 0 No Type of perforator used _
No.of perforations Size of perforations in by in Driller's Log/Construction or Decommission Procedure
Formation'Describe by color.character,size of material and structure,and the kind and
Perforated from ft to fi below ground surface
nature of the material in each layer penetrated,with at least one entry for each change of
Screens: 0 Yes 0 No ❑K-Packer b Depth ft. information. Use additional sheets if necessary
Manufacturer's Name Material Front To
T>lu Model No. Lt Brn boulders cobbles gravel sand silt 0 3
Diameter Slot size in.from ft to ft.
Diameter Slot size in from It.to ft LI gray cobbles gravel sand silty clay 3 28
LI brown cobbles gravel sand silty clay 28 125
Sand/Filter pack:0 Yes No Size of pack material ___in
in LI brown cobbles gravel sand Silty clay saturated 125 134
Materials placed from ft to 0
-- Lt brown cobbles gravel sand silt some water 134 150
Surface Seal: 0 Yes 0 No To what depth' 18 ft Lt brown gravel sand silt some water 150 165
Material used in seal BENTONITE CHIPS -
Did any strata contain unusable water" 0 Yes 0No
Lt grayish brown gravel sand silt water 165 176
Type of water Depth of strata Lt brown gravel sand clayey silt 176 177
Method of sealing strata off
Pump: Manufacturer's Name Type
N.P. Pump intake depth:_It Designed flow rate gpun
Water Levels: Land-surface elevation above mean sea level ft.
Stick-up of top of well casing+1 ft.above ground surface
Static water level 131 ft below lop of sell casing Date 09/22/2023
Artesian pressure lbs per square inch Dale_
Avestan water is controlled by (cap.valve.etc)
Well Tes ts: ,
Was a pumping test performed? 0 No ❑Yes b by whom?
Yield gpm with ft drawdown after hrs.
Yield gpm with—ft drasdown after _tits
Yield _gpm with ft.drawdown after hts
Recovery data(time zero when pump is tamed off-water level measured from well
top to water level)
Tunic Water Level Time Water Level Time Water Level
Date of pumping test _
1
Bailer test gpm v.ith ft drawdown after tin -------
Air test 20 gpm with stem set at 174 ft for 1 hrs — Date 09/22/2023 — —
Anesian flow ppm _
Temperature of water "F Was a chemical analysis made? 0 Yes 0 No Start Date _ Completed Date
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
El Driller 0 Trainee D PE-Print Name Mark Wiese Drilling Company RICHARDSON WELL DRILLING
Signature .- • 4"--4---.14 Address PO BOX 44427 _
License No.2432 City,State.Zip TACOtv1A•WA 98448 _
IF TRAINEE:Sponsor's License No. Contractor's
_Sponsor's Signature Registration No.RICHAW'3210B Date 09/26/2023
ECY 050-1-20(Rev 09/18) If you need this document in an alternate format.please call the Water Resources Program at 360-407-6672.
Persons with hearing loss con call 711 Jar Washington Relay Service Persons with a speech disability can cal1877-833-6341
•
RICHARDSON WELL DRILLING
Aquifer Test Data
Well ID# BPS-260 Owner: Frank Marcinko
Site Address: 797 NE Blacksmith Dr
Pumping Well Parcel#: 22310-79-90663
Pump On 06/18/23 12:30 Pump Off 06/18/23 14:10
Date Time Date Time
Reference Static Level 130.20 Feet Pump Size 1.5 HP GPM
Recorded By Time Water Levels
Date Clock Elapsed Time Reading In Depth To Drawdown COMMENTS
Since Start Gpm Water
PATRICK 6/18/2023 12:30 0:00 6 130.20 0.00
12:32 0:02 6 132.80 2.60
12:34 0:04 6 133.00 2.80
12:36 0:06 6 133.10 2.90
12:38 0:08 15 137.30 7.10
12:40 0:10 15 137.30 7.10
12:45 0:15 21.5 143.40 13.20
12:50 0:20 21.5 143.70 13.50
12:55 0:25 21.5 143.70 13.50
13:00 0:30 21.5 143.70 13.50
13:05 0:35 21.5 143.90 13.70
13:10 0:40 21.5 144.00 13.80
13:15 0:45 21.5 144.00 13.80
13:20 0:50 21.5 144.00 13.80
13:25 0:55 21.5 144.00 13.80
13:30 1:00 21.5 144.00 13.80
13:40 1:10 21.5 144.00 13.80
13:50 1:20 21.5 144.00 13.80
14:00 1:30 21.5 144.00 13.80
14:10 1:40 21.5 144.00 13.80
RECOVERY 14:11 1:41 131.60 1.40
14:12 1:42 131.60 1.40
14:13 1:43 131.20 1.00
14:14 1:44 130.90 0.70
14:15 1:45 130.60 0.40
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; MANAGEMENT
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Min LABORATORI ES st4c.
UMW 1515 130th St E.Tacoma,WA 98404 '
NIIIIr I COUFORM BACTERIA ANAt YSIS FORM
Date Sampe Cotlected Time Sampe County .•
Coreried
' /6 1 M 1 Z3 0,.•
Type of Water System(check only one box)
0 Group 4. 0 Group El aes9ttir f
—-4
Group A and Gto.ip S Systerns- roi,de from%Vine Fa;•• t-f-s m.emorj,AYR. 1
IDd rik,:nt'S___ 4...fc.;_toltl__
System Name i
Contact Person 'iron Leeper --
I ,
Day Phone f 253) 5.??—7332 1 CettNone i 2 —53 377-0236
_
Email ; Eve Fncne i
— --,
Send rtsJ ts'f, ,,I:•:Lu ,ert.soesS in,al:CM
• 140aFdson_Well D411ipq
PO Bor. 44427
i . ... . _ . _..... .
.Tacoma,. WA ._ 98448 1
SAMPLE INFORMATION
—--1
Sample collected by Memel'
Patr i C•K
, Specific button where samplered• . So..-.•;1.-str.::1.:r.,1 c•••ontresits
,-..arrivtAt 7/7
B.I.. .1cS.Biliti— f__ .
Type ot Sampk(seleCI Only one type ol sample koni rypes 1 Vircup 5 Lielowt
1 0 Routine Distribution Sample(AP) 2 0 Repeat Sample(AM)
!tax:dir Lt:xis:.sterr Mel kritat rural%
_•
CnIonnated Yes r:- - _
unsabsiacpri routne lab-.unit&
Chlonne Reseq.a: Th..e..._ _ Free _
3 Ground Water Rule Source Sample
UrisaliSfacKry tculirie coliect Gate
i......._,S
Chl3nriatec Yet__NO.
D Tnggered tA•P. Cntortne Resoiat Iota' _Free_
0 Assessment i AIP
4 Surface or GWI Raw Source Water Sample tErtoreron)
S 1 • 1
iL._:._............j
0 E CO 0 Fftvi :•N.! f 0 •
I , 5 CI Sew,'Ca;ened fo.Information Only:
LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Colleen;Present and
C)E col'present 0 Etok absent
Satisfac
, 1
. •
Bacterial Density Results Total Coon____ .._,.,100of E cor/._ _._ ._100m1
Fecal Cordon 0100ml. HPC il mi
. - .- --
Replacement Sample Required: 0 TNTC 0 Sample too ola
0 Samote Volume CI Damaged Container 0 .__ _._
Datemme , 1,4-0 6 . 1 L,t,Refrenle Number Ai isa.. j )
lc)
Receipt Temp C. 0.4etnonCoos.5 i)q.-).19,6
i Dale .ed to OOP 01 t lab the Ori) AR].8314
DOH Lab-Sampee
V-----
,..--• ...--1,.......r) 1
089 b t,-7 1_,1 i
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t:.Fr"-elf e.7,%f,::•,zeK.f. NI,,...c,.,1...'",`-..:-..•t-. • .•-•••• -€ .tP 7,,t'-r.51,y..."711•
Return To 2204823 MASON CO WA
fraiLI`ha�,�Ina 11/22/2023 12 28 PM NOTCE
MARC!!! IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Pages
1111III
sd 77 emit?, L N N!✓
54et.de Gh, WA Q83 'o
Grantor(s): (1) it�at-ref ` 4E41 LKo (2) gaze /%tJyi /�i'p I'#AO
Grantee(s): (1) PUBLIC /
Legal Description (1) T R[�6 ®f.570V 107 rife 3 Of s p °:t795- v't63.S388
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 42 3 j 0 - 7 ? - T a 6 6 3
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) 01 oZ .3 / 0 - 7 9 - IO t7 6 6 3
Tax Parcel: (Connection 2) 02 a . 3 1 0 - 7 Q - 6 6 I
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Fro,/ Ne f/ow �a'-�
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 o` v day of /► , ider , 20
Signature of Granto s):
(1) , (2)
Page 1 of 2
State of Washington Lr/fi-S/1447-i/)
County of 441 /r3eLP )
I, the undersigned, a Not r Public in nd for the above named County and State, do hereby
certify that on this ay of AI 2_, 20 Zd ,
koef, !/lek‘ ersonally appeared 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 . 7 e written.
Al .r..,,,A116 .„,m, 4
411,
Notary Public Nota v =tw. IMIEW.r e St. : of Washington,
State of Washington residing at / , _ d _- _'
BETH A ALEXANDER My .mmission expires: / /
COMM.EXP JANUARY 12,2025
COMM. NO.3444
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Page 2 of 2
i
/ /Well radius for 22 •-79-90664 f I
+0'el 184.83' ansformer rA I
• d Qtr
/1, I Q,oa ••�c�c` as
�" i ,,d ��. Sic. �o
Parking& �\si i ,e ac`E -(o
Turnaround base�c,0��a�oe
Area I o ��s
\All / c°°v/ I 'Lg6
>co/
a/ 1�Proposed New
�� .i • i 200 Amp Service
r, �� ' Pump I Conduit&Wire
'� Tank
VB Sep c. I ril'It
h 0 Tan / a
' a~Proposed New
n I! / Water Line For The
100%
Reserve. �I�e\\Iva o •a co dPet r,, House
221310 9 90661
eter
1� S.1' .°ye : j
X
n SL#3 ��� Qc°e: owe fr
It ..
0
Downspout Drainage • ' ~/,•' qCP��ay°�'
Line to daylight '� ,' "" Planned
Rain Garden/
%t �\;... . e<-;' Runoff
cN ,•o ,L,• Retention
_�!'% tee•a� t), Area
' Q,e ens o�,e, c�
Q '
P ' ck-
-. ,cep e,
t., t•.•
• .•.L a\\CQ��
• z Proposed soc ate¢`
Well it;
—--•• —-4:....,.._,..
/
642
yd
+5' el 184.46' +9' el
Building Site Plan Name: Marcinka Tax Parcel: 22310-79-90663
Scale = 1" = 40' Address: 797 NE Blacksmith Dr, Belfair
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