HomeMy WebLinkAboutUntitled (2464) nth A
MASON COUNTY 415 N 6TH STREET, 0-427967 , 98400
SHELTON:36 SHELTON,42 EXT, 400
584
BELFAIR:360-275-4467, EXT 400
Public Health & Human Services ELMA: 360-482-5269,EXT 400
FAX:360-427-7787
NEWTON, RUTH and JAMES
4421 E NORTH ISLAND DR
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00017
4441 E North Island Dr
221251100080
The 2-party water system, North Island Water System (221251100080/221251100010), has been
4 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
-� �F,,, MASON COUNTY Date Received: II `
,i I• 1 COMMUNITY SERVICES A grillio
a ex
` Building,Planning Frwironmen,al Health,Community Health
' .
415 N.6t'Street,(Bldg 8) Shelton,WA 98584 W EL 0 1..4 .
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATIO MAR 2 6 2024
APPLIC T ' PHONE ..,rk�+ � (Ihmaf twforl ff jHnie � 60~�l�b�51�9 �-2��1 �b3
MAILING ADDRESS-STET,
CITY,STATE,ZIP
12; E A/or•�-{\ lslAnd Dri✓� She1 -on/ �;/,t4 gIb35 Y
SIT ADD ESS-STREET,CITY,STATE,ZIP
` ` u1f h .:CsIan� -)r'tvt' Sie,1-�-c�rA l,V `'1Y5 ►
PR M R ARCEL NUMBER(WELL SITE)
U.)-1a5-Eli- O ')OfO
SECONDARY PARC NUMBER(IF APPLICABLE)
12P"y-•1I —600(Q
WATER SOURCE 1 SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New )0 Existing IA Well 0 Spring (o 5-7
PROPOSED WATER SYSTEM NAME(REQUIRED) l �c
PROJECT DESCRIPTION
DIRECTIONS TO SITE/CONDITIONS
le.4 a.-c. +e,r 0-o,-,s(9 11ridie, (N,rj-h Idand D,,), Go �� piles,
\)v6-42A.,la, on lec—c-, 1 hick# M ai l bvxe5 eQctoss From. cirike .uJ''t-yf
Site Plan: (may also be attached)
(property boundaries, structures,well site w/100'radius,driveways,roads, septic/sewer components and lines,easements,etc...)
See i//c, kI
Q
I MAR 1 9 2024 U'x
By --r- _'
Submittals Checklist: (these additional items will be required for approval)
Cjr 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)
17.1 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
ltn, ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings: indicate distance on plot plan)
❑ pIDAre there roads within the 100 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory? l I*le.
❑ cr El Screened and vented? �l 1
❑ The well casing extends i above level ground I �rete .lab? (circle one)
❑ ❑ Is there evidence of a surface seal? C.att i17 Z�yZ ��
❑ El Does the seal appear adequate? t Orl l -(2 Z.$683US6
❑ IV ❑ Is a variance necessary for well site approval? Tug; ill la
Comments Olvibur sloikeispyr Lvvviddecn 014lig, tof,/1/.-t d!r /
eAilrx lee .
Pass ❑ Fail Inspector
y Date 3t 20 241
Review Step 2: Two-Party Review:
YES NO NA �r6o� : ��00 dl
[ � ❑ [1] Water Well Report with adequate pump test on file? ft(Z(/?Fe 30 GfR
If NO, date of Capacity Test.3(t4/Z021( Driller itaCidta Oi GPM 20
X ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test Received Si Z(ZZC Z� wool for ItCoii-L
� ❑ ❑ Signed, Notarized, and Recorded Notice? AFN ZZ0 g`I{y-
7" ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
fit- Approved ❑ Denied Reviewer Date y/(� ?j
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 1701'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
Copy with
DDeepeutmentt O and riginal
logy WATER WELL REPORT Application No. .
Second Copy—Owner's Copy
Third Copy-,-Driller's COPY STATE OF WASHNGTON Permit No. ....
(1) OWNER; N Robert Ireland_ _._....._..._.»..._—____—__ Address__-Rt•4..._...__.Shelton� Wash, $ +..._......_........_..._..._....
L �
O (2) LOCATION OF WELL: coon: .._..._1'�& QA_...-------------_.- _..._.....__..._.............— .IE i: ..NE' _..3 sect.._. T'1 _rr.,> _.v!!w.nt.
C Searing and distance from'action or subdivision corner Sec. 25-21-2
Y (3) PROPOSED USE: Domestic i industrial 0 Municipal 0 (10) WELL LOG:
a Irrigation 0 Test Well 0 Other 0 Formation:Describe by color,character stre o1 aterial and structure,and
show thlckneu of aquifers and the kind' ►m
.and nature of the material in each
(4) TYPE OF WORK: Owner's number of well m penetrated,with at least oae entry for* torb oom of formation.
H (if more than one).... MATERIAL PROM TO
New well Method: Dug 0 Bored a
a=.+ Deepened 0 Cable Joe Driven Q ------- - --- -----
C Reconditioned 0 Rotary 0 Jetted 0 shot clay 0 10 1—
O blue clay 10 98'
c (5) DIMENSIONS: Diameter of well .............._6„..L..... inches. sand , 98 115'
O Dewed. 163-.._.ft. Depth of completed well 16 _.__sc cemented );Tavel 115 1
6.1
ftt
E (6) CONSTRUCTION DETAILS: gravel & water 150 163-i
s- Casing installed: 6--_.. Dian from __.0...._.. ft.to 163 . ft.
Threaded 0 ..»_ _—"Diem. from .._......._.. ft. to _____ ft.
Welded, ...._ _..._" Diem. from
Perforations: yes 0 No,$ --,
L. Type of perforator used............_..._.._._._....._......__..._._..._..._. ...__.___..
Q SIZE of perforations ..- ..._...__._.—.._. fn, by ---•---- .__._.__. ln.
perforations from —.._..____. ft. to ..-_.-__—_.. ft.
R _ perforations from ft. to ._......» .__ ft.
CV
4-0 SCiBellt: yq 0 Nog ft
WED
0 effilleeciManufacturer's Namecu
......_
ate+ Diem. ._......__..Slot sloe ...... _. from ..__.._..._ ft, to.__ ft OCT
6 1918
cGravel packed: Yes 0 No/ size of gravel:-_.__._._._».__....
i Gravel placed from___.-..._-._.__.__..ft.to_._.._...._._..._._..._.ft. EPARTME4lT �� 0 OFFICE
SUUtNWEST �
S Surface seal: Ye4 No 0 To whatdepth?
Benton �e 1
Material used In seaL...._.---..__...___..... —
~ Did any strata contain unusable water? Yes 0 Nosy/
O Type of water?. ..........__._..._.._.._.. Depth of strata...._.__._..._.__._..._
Z Method of sealing strata off_..._._......................_.._..._.....________
O (7) PUMP: Mau ac ursI (3e. Flint Walling . _ - __
� Type; .._..._..._...__..._.._.._..__.__._ »_.._ _._.._..23P._�A J
>+ (8) WATER LEVELS: d-eurrace elevation 30
� 128 above mean sea level.... .._._.130__.:,.
Q Static level .ft.below top of well Date...._________
O Artesian pressure _........_........_...._...lbe. per square inch Date...._._._.-_.._......_
C.) Artesian water is controlled by _..—._. ._..._._.......»....
W (Cap, valve, etc.) _-__-� _-.-----
`~ (9) WELL TESTS; Dray/down is amount water level is — _- -- —�7 7
Q low below static level Work started ___Aug..2'�-__, 19.f.r�ilQ... compieted_.__..Ae t.r..__t-...is...[.8.
++ Was a pump test made? Yes 0 No If yes,by whom?
0
0T:Yield: galimin. with ft. drawdown alter hrs. WELL DRILLER'S STATEMEN
�E+ - true to the was
eat of drilled knowledge my jurisdiction
d e)i i n and this report is
L.
a Recovery data (time taken as zero when pump turned off) (water level
measured from well top to water level)
Time Water Level rime Water Level Time Water Leval NAME...Bedell-- 1m, fir .•,i l tr.Q.r
Q (Person, firm, or corporation) (Type or print)
U Address1,583 E. Dickinson St. Shelton, Wash
Date of ?sat rr (signed]
- 11 4... i.
Bailer test.._._30 gal.min. with_.__i.5 it.drawdown after.._.1.___..._hrs. (Well Driller)
Artesianflow._._.._..._... ...»..._...».........._..-g.P.m. Date...._................_.__._.—.__... .... 8
Temperature of water Was a chemical analysis made?Yes 0 N� License No. 0032, Date Sept.12 19 r
(USE ADDITIONAL SEXCTS IF NECESSARY) '�'
s
ECY 050.1-20
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Ruth Newton Well Tag#: None
Site Address: 4441 E North Island Dr, Shelton Depth: Unknown
Date of Test: 3/12/2024 Static: 125'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY
1 Min 20 127.1 TIME LEVEL
2 Min 20 127.3 1 Min 125.4
3 Min 20 127.3 2 Min 125.3
4 Min 20 127.3 3 Min 125.2
5 Min 20 127.3 4 Min 125.1
6 Min 20 127.3 5 Min 125
7 Min 20 127.3
8 Min 20 127.3
9 Min 20 127.3
10 Min 20 127.3
15 Min 20 127.4
20 Min 20 127.4
25 Min 20 127.5
30 Min 20 127.5
40 Min 20 127.6 CUSTOMER
40 Min 20 127.6
45 Min 20 127.6 ®I"'�y
50 Min 20 127.7
55 Min 20 127.7
1 Hr 20 127.7
1 Hr 10 Min 20 127.7
1 Hr 20 Min 20 127.7
412 Lilly Rd NE
Olympia, WA 98506
360 867-2631
THURSPON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
2— 9. / :2.64 MaSon
Month Day Year
p D PM
Type of Water System(check only one box) El Private Household ElGroup A CIGroup B gOther pct,r+y
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: hlv �kv.J+O n
Day Phone:( ) i Cell Phone:(3W .-)92g 'J(Oa •
E-mail:lit;J1Q,Lt:TCfi iv sn, Cod) Eve.Phone:( 960)'/Z& I3?
Send pc ults t:(Pri t i i name,address and zip code or email address)
N +ci
44.21 C= )jc IA Is)arid brI v'e.
1,414 qF6vii
SAMPLE INFORMATION
Samplellute�d�y(name ` n
Sp'cific`I c tion�addrgs where sampleO
collected:, Special instructions or comments:
Type of Sample(must check only one box of#1 through#4 listed below)
1.0-Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes Now XDistribution System
Chlorine Residual:Total Free___ Chlorinated:Yes )( No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli—GWR(Ali))
El Fecal—Surface,Gwi,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
El Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S
4.0 Sample Collected for Information Only
Investigative___ Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present E)E.coli absent
o Coliform detected
Replacement Sample Required:
El Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli /100mI.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code: SM 9223E ❑SM 9222D Date and Time Receiv :WOO
�SM 9215B ❑Enterolert® 9- 2(
Date and Time Analyzed: —a Date Reported:ZI 1212 A 6
Sample Number(DOH number plus five digits) Lab Use Only:
0 8 0
DOH Form#331-319 tensed 01/16)
2208247 MASON CO WA
II0NEWTON II''3/05/2+0+2I4II''JJ03.17 PM NOTCE I� II + f I 1 ++
Return To 1 N1ii It Ill JI tun�Ii�I I lvii �llf1 vi ll��I
NeAvfoJA
1trcve
.5he-1- tl WA qg
Grantor(s): (1) Rut_.N_Lmer' _fie , (2) ---, , af -Ere-IAA,
Grantee(s): (1) PUBLIC Uvro/A
Legal Description (1) 5 2 , 7"21 k2
(Abbreviated form: i.e. lot, block, plat/or section,township, range)
Assessor's Tax Parcel: (1) .? - _L_ 1_ - -_ _a - E_
22 I 25- - / 1 -- 00 0 ( 0
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) _A. A_ 1__ .2_51_- -
Tax Parcel: (Connection 2) _1 1 .I__ _ _ - _ _ 1_- - _iceC a
The system owner is responsible for keeping this system In compliance.
The name of the water system is: ...4) '2, ✓ -fie-1 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 6 day of /k5 YA
Signature of Grantor(s):
1(1(1) ""`�- - `--- , (2) gtee_te
Page 1 of 2
State of Washington )
County of Mason )
1,the undersigned, a_NZary Public and for the above nameci County and State, do hereby
_cgrtify that n this y of_ _ -6-- , 2 E,
ida ' W4441- personally appeared before me,who Is known to be
signer of the above instrument, and acknowledged that he (she 1L gned it
GIVEN under my hand and official seal the day an r last above written.
P�� V rRgL%/ ota ublic in and for a Sta a of Wa ington,
. .. sion / . L __�� J ma`s 5.2 Fl ;' s�.S residing a L I ' ki _
:c° NpTARy N My commission expires: __ 3
r►.40 o:
%1 % p16t\G\o;a 0 =
E
,i'.e/1'Umbei2•' \C
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i////,OF'WASN\\\\\��
Page 2 of 2