HomeMy WebLinkAboutUntitled (2330) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
r BELFAIR:360-275-4467,EXT 400
"'
IP. 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
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
. "\ Date Received:
ltroci ..1,„. MASON COUNTY 3ictis $ \ _
�. .l , , COMMUNITY SERVICES Amo t eaAir-Building,Planning rnvtronmental Health,community Health
415 N.6th Street(Bldg 8) Shelton,WA 98584 W E L ' .O9 .-
Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elma:360-482-5269 x400 h,.
TWO-PARTY PRIVATE WATER SYSTEM APPLICATIO MAR 2 6 2024
REC�cr1jE
APPLICA'' PHONE
JT J��� f U I f C r ( fllt �JY1O--�1,2I 51'39 : O-22y'_�t be
MAILING ADDRESS—STl fIll (t ET,CITY,STATE,ZIP
Itli 21E 41or ks(altd Drive. S'Aej1Oni VGA y8S8tf
SIT ADD ESS—STREET,CITY.ST TE,ZIP
J// ' NIA''1) .5l0-A Dr�i, vz SIei-1-0nA \,'alp �1S'
PR M R PPARCEL NUUMjBER(WELL
SITE)fV�
SECONDARY P RCEL NUMBER(IF APPLICABLE)
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New X Existing Well ❑Spring („ ;.�7 Pi. 5 7
PROPOSED WATER SYSTEM NAME(REQUIRED) !!
PROJECT DESCRIPTION
DIRECTIONS TO SITE/CONDITIONS
1e.4 cti- i.zr c totsi129 ri dl e- (1\1Gr srh IdetiAA '-‘'r), Go 24,)4 rp , ks,
brtveU.,Ik / or\ lecl-, 1 1)61._ct< m a1 1. U0XC (,ctess TSe,m JSl(e_UJcyc
Site Plan: (may also be attached)
(property boundaries, structures,well site w/100'radius,driveways,roads, septic/sewer components and lines,easements,etc...)
S
MAR 1 9 207.4r ,, , , , ,,
. By..._-•—*--------\
•-•--1
Submittals Checklist: (these additional items will be required for approval)
Cjt Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
I ' Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
a Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
It 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
rminommilimemmw r
Staff Use Only --------__._w
Review Step 1: Well Site Inspection:
YES NO NA
®n ❑ ❑ 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.
r What is distance to ROW?
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
)11
❑ ❑ Is the well cap satisfactor�`dr
❑ J El Screened and vented? t
❑ The well casing extends ` above level ground I oncrete .lab? (circle one)
❑ ❑ Is there evidence of a surface seal? Laf t T ,Z��{2 ��
❑ ❑ Does the seal appear adequate? LOn; -12 2•$683cg
❑ NA ❑ Is a variance necessary for well site approval? T41' Afl'a-
Comments CWi rsift 54r tyva � decn old_ to r (f�y� it At t_jam'/`
�, . ;tote .
Pass ❑ Fail Inspector ________Ir2_,X. Date 3/Z2o ZV
Review Step 2: Two-Party Review:
YES NO NA 4r- = 1?",a1
❑ ❑ Water Well Report with adequate pump test on file? ���Z��`��8 3o G�� Oit
If NO, date of Capacity Test.10Z021t Driller Arcata O(11Z GPM 20
, I ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test Z(ZZ 9' 2o4p Co' IZORii -,
L`
Received Signed, Notarized, and Recorded Notice? AFN 2 n
Z0 b LIT
7" ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
#- Approved ❑ Denied Reviewer Date ((/(( zj /
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 ofer January 19th, 2018 per ESSB 6091.
Revised: 10/1 3/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
File Original and First Copy with
Department of Ecology WATER WELL REPORT Application No. . .
Second Copy—Owners Copy
Third Copy-.-Drillers Copy STATE OF WASHINGTON permit No. .... .
(1) OWNER: Nam, Robert Ireland_..._-_....._.._._.._.._.-__-._— Addrem._.__..•--..._..._ Shelton,. W.a.s.h.,..._0584
p (2) LOCATION OF WELL: count..._-.._.1!.QA_...-------- __. _..__.._....._....._.............— .NE 3. ..NE....v. see, -.. T..i ..N.. FeR_.16.424.
alBearing and distance from section or subdivision corner Sec. 25-21-2
Y (3) PROPOSED USE: Domestic Industrial ❑ Municipal ❑ (10) WELL LOG:
a Irrigation 0 Test Well ❑ Other 0 Formation:Describe by color,character size of and structure,and
land
show thickness of aqufiffere and the and%atsrt flue material in each
(4) TYPE OF WORK: Owner's number of well stratum penetrated, to(th at least one entry 1. . e>t, ,—.of formation.
_ _ .
N (if more than one).... ......... __....._......_._. MATERIAL IROM TO
New well ., Method: Dug ❑ Bored 0
F=+ Deepened 0 Cable Jj Driven❑ ------
C Reconditioned❑ notary p Jetted a shot claY 0 10 i
O blue clay 10 98'
_ (5) DIMENSIONtN�jS: Diameter of well 6 . inches. Sand 98 115'
O Drilled . 1_S1J—.._.ft. Depth of completed well...-- 163_.__ft.
P ggsented�>Pvel 115 150'
e3 gavel water 150 163 t_
E (6) CONSTRUCTION DETAILS:
Casing installed: 6 •' Dian. from __0...._.. ft. to_163 ft. - —
.- Threaded 0 ...._.._—" Diem.from
— Welded -.__.._.-" Dian.from ft.to ...._....___ft. —
Perforations: Yes❑ Nose r'
Typeof perforator used......._..._.._....._._...._......__..._. ._.._. ...__.__.... r
Q
perfontiooa from —_•--..._._.._. ft.to _---- rt.
perforations from
R ....__. _-.....__ perforations from _..._....._._.._.. ft. to ._._ _ ft_
03
03 Screens: Yes❑ No CI RECEIVED .
CIManufacturers Names......_._-------._..--..__...__.........__...___.._.__._.
tL Type_ Model No......_.__—__...—...
.0 Diam....._..._..._ Slot Size_.—__...from ...._._.....__ ft.to --..__—ft.Diem. Slot size ....__». from ..__..._.__ ft. to. .... ft. OCT
6 1978
C __.__.
Gravel packed: Yes❑ No/ Size of gravel: _._..._.__.... LOGY
a- Gravel placed from___._....__..__.__._....ft.to_._.._..._-_..._._...._..ft. SUUT S SE OT Of hp OFFICE
WIEST
eta Surface seal: yes,/ No 0 To whatdepth? ___..18....._._. ft.
Material used in seaL_. .--- ntoe -
1—, Did any strata contain unusable water? Yes O No(
0
z Method of sealing strata off_..._._.-_.-..._..._........._.._..-_......_._._.___..
0 (7) PUMP: Mau ac urs��ee. Flint wa111r1g _._.__... . ._ ---------
13
›N (8) WATER LEVELS: Land„e smurfaceane sea le elevaveln .. .._.....139_Ittio - —
� 128 abo ..o Static level .ft. below top of well Date....._._..._._.._....._.
O Artesian pressure _........_........_...._...lbs. per square inch Date........----
O Artesian water is controlled by.__._.-.. _..—.__ .—._._....... ....
W (CaD, valve, etc.) -
_—_ ---
y" Drawdown Is amount watts level is -- —
9 WELL TESTS: — -- p Q .i ry
Q ( ) lowere below static level W started____AItg� __19.78... Completed._.__..lLse�t!___t....Io..:L-.-.
Was a pump test made? Yes❑ No If yes,by whom?
(v Yield: gal./min.with ft.drawdown after hrs WELL DRILLER'S STATEMENT.
s—
his well
under
„ r true to the be asst drif lled
knowledge and beliein and this report is
Q Recovery data (time taken as zero when pump turned off) (water level
measured from well top to water level) nw
Time Water Level Time Water Levee Time Water Level NAME.-Be tell(Person,
Zit sg••?tit.,
Q (Person, firm,or corporation) (Type or print)
O Address 158J E. Dickinson St. Shelton, Wash
s
Date of test (Signed] "�'!z j 4..e:d.
Bailer test.-_-_30 gal./min. with_.__1.5 St. drawdown after..___. ---...._hrs. (Well Driller)
Artesianflow._._.._..._..._..._..._..............._..4 p.m, Date...._..._..........._.__._.—.__..._._.
Temperature of water WAS s chemical analysis made?Yes 0NV License No 0.032. Date Sept.12 78/9 ._.
(USE ADDITIONAL sIEXCTS IF NECESSARY)
s
ECY 0501.20
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 ®p,Y
50 Min 20 127.7 1""
55 Min 20 127.7
1 Hr 20 127.7
1 Hr 10 Min 20 127.7
1 Hr 20 Min 20 127.7
I
i
I
I
I
412 L.illy Rd NE
Olympia, WA 98506
360 867-2631
THURSPON COUNTY
mormeramseei
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected �A
'2- . m� %�5� oACA4 /VI Qn
Month Day Year
Type of Water System(check only one box) ❑ Private Household
❑Group A ❑Group B [ Other 'Z P(t r.*/
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name: LL
Contact Person: RA t�,UTO Irk
Day Phone:( ) Cell Phone:(30 ) 2,1.•/60? •
E-mail:TW e;,U�'Cf1(c 1.jnsrh coA1 Eve.Phone:( /26-Si3%
Send ults``tqq:(Pri t f I name, dress and zip code or email address)
u th NeWtMlt
4 4.2 f e; /lfv r fh I )and bri ve-
SAeft()n, VIM cTS5r8'
SAMPLE INFORMATION
Sample cell(1ttidby(name): n
Specific location o addro whefi sample� colle�tedk Special instructions or comments:'/y Ur 04K r
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 tC_ Distribution System
Chlorine Residual:Total Free Chlorinated:Yes a( No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.col i—GWR(A/P)
❑Fecal—Su-face,GWI,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑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 Colifonn Present and Satisfactory
❑E.coli present ❑E.coli absent
o Cafrform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code: SM 9223B OSM 9222D Date and Time Receiv :[OD0
�SM 9215B ElEnterolert® 9- 2 _3 tes
Date and Time Analyzed: —a I_a Date Reported:ZI zz jia V
Sample Number(00H number plus five digits) Lab Use Only:
0 8 0 (`%
•
DOH Form rm#331-319(revised Otn, Tir +, 3
2208247 MASON CO WA
03/05/2024 003.11I71 PM 1 IU1 II NIIIItI1!I
Return To R_u_A eAe fo_A i11 N lioI IslI�4MIIIIIIIIIj 3nhI,HoIIJ rllNitaflfl
_5 he_l r 9 '
Grantor(s): (1) RuA__,NCifer _ �s</�'�— , (2) 'Afar--- C (1 _1 . Y'eLOA
Grantee(s): (1) PUBLIC �" 1/4,4s
Legal Description (1) 5 2 5 7-2/
!2
(Abbreviated form: i.e. lot, block, plat/or section,township, range)
Assessor's Tax Parcel: (1) 2._ I__ _-S_ — _Z_ 1_ — 0_ O o_
2 21 ifU
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,. i_ 1__ _2_ - - _d _Q_
Tax Parcel: (Connection 2) J__ _ a2_ - _4_ I__ -
The system owner is responsible for keeping this system in compliance.
The The name of the water system is: ...2 -D� -te-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 _J' day of .6 r ,
Signature of Grantor(s):
ilv-1441//c-----/-7
(1) t'�. . — - .�_ . (2)
Page 1 of 2
State of Washington )
County of Mason )
1,the undersigned, a --ary Public i and for the above nnaame� County and State, do hereby
.fidrtify that n this d y of_ _ �`- , 2O t
t CO personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (she -') gned it.
GIVEN under my hand and official seal the day an r last above written.
/ L2M
.. N �..rR,q /, ota ublic in and for a Sta a of Wa ington,
�,„,-D..C..\sslo p'4,O,,,,,,i, residing aL L.lL-_ - + , ��J -
:c° NOTARY " ' My commission expires: __ g`�
- +•411111 _
mPUBL\G �a'Z`
/%,liSeN1,mbel`1'10..c.,
/i,F OF"Illit1wASN\\\\\
Page 2 of 2
Z ' / ,,T-o '
WEL1-02A- 000 L1-
"e--1%/7
at .).. - _ ‘ 1, _0008a v_. yyy/ dit'itib
vm jAe/104 144-
, i--(551.71
_ c ,
v ) JO,229,._... 02,, ,...5Z.0
9t‘. 0
z_ 2-'
4,,
cif
4:
% (
1
f�4\ oc______,-, , o'll
1
. ,
-, /y(2
oy0 0, ,,,4,
I oll
,.. ,/,,. / J
\ /,./ 18c,,7 !
,,, ___
l'4' '' . / _.
,i,‘2 __,„._--- .,,,,
. .k, ..
,,, ., .--',i, uP
) I,- ....z Ian
v ...., ...',.: \ I , Y)
. .
,,
__ ,
\ s,. 10