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Home My WebLink AboutUntitled (2690) • MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 J Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 VAN ACKEREN, CHRISTOPHER EDWARD 60 SE SELLS DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00013 60 SE Sells Dr 319024390021 The 2-party water system, Wells Farm (319024390021/319024390021), 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 ■ d'i R Date Received:MASON COUNTY ¢ , � = 11. COMMUNITY SERVICES Amou R eived ReceivedBy: ✓' -�- r iP / ildinq Planning,Environmental Health,Community Health W E L () �,11 C�415 N.(i''Street,(BldgR)—Shelton,WA 98584 6-6 I Shelton: 360-427-9670 x400 13e1fair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION • APPLICANT PHONE CHRIS VAN ACKEREN 514-913-0950 MAILING ADDRESS-STREET,CITY,STATE,ZIP 3810 SE LYNCH RD. SHELTON, WA 98584 SITE ADDRESS-STREET,CITY,STATE,ZIP 3810 SE LYNCH RD. SHELTON, WA 98584 PRIMARY PARCEL NUMBER(WELL SITE) 31902-43-90021 SECONDARY PARCEL NUMBER(IF APPLICABLE) ?Igo2 (13 looz WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑ New XExisting I \'Nell 0 Spring 4.19 ACRES PROPOSED WATER SYSTEM NAME(REQUIRED) WcUIS FWA1 PROJECT DESCRIPTION TWO PARTY WELL PERMIT FOR NEW PRIMARY RESIDENCE CONSTRUCTED. EXISTING RESIDENCE ALREADY SERVED BY WELL WILL BECOME ADU DIRECTIONS TO SITE/CONDITIONS FROM DT SHELTON, TAKE WA-3 S. TO OLYMPIC HWY S. LEFT ON SE CRAIG RD. LEFT ON SE COLE RD. LEFT ON SE LYNCH RD. RIGHT ON SE SELLS DR.. SITE IS ON RIGHT Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) FEB,-2 2024 LJ Submittals Checklist: (these additional items will be required for approval) — ® Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) 81 Well Log with pump test or 4-hour capacity test performed by driller (this may be deferred if well is not yet drilled) El Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) tEl 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: L COW, YES NO NA M ❑ ❑ 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? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) 71 ❑ ❑ Is the well cap satisfactory? ;if.] ❑ ❑ Screened and vented? ❑ The well casing extends — I Z above level ground /concrete slab? (circle one) �] ❑ ❑ Is there evidence of a surface seal? tAf: 'Li7.1596ij6 J ❑ ❑ Does the seal appear adequate? WI! ` l 2 j•o Zao M ❑ c0 ❑ Is a variance necessary for well site approval? Tky: ALl(/O9 1 Comments pi Pass ❑ Fail Inspector Date 3/71 7oZtf Review Step 2: Two-Party Review: YES NO NA ❑ ❑ ❑ Water Well Report with adequate pump test on file? ZOJpPI X60"'n = (700,41 If NO, date of Capacity Test afro Zo I Driller A(COdnt Oy1th GPM Za ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ;/f l7(fjc ` t ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z 2d$G fs ❑ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments yApproved ❑ Denied Reviewer Date i(l U( t!OZ 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 alter January 19th, 2018 per ESSB 609/. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 a r WATER WELL REPORT (j•.--I DEPARTMENT of Notice of lntcnt No. WE46374 ECOLOGY Unique Ecology Well II)Tag No. ALN049 Type of Work State of Washington Site Well Name(if more than one well): O Construction O Decommission Original installation NOt No. Water Right Permit/Certificate No. Proposed Use: 0 Domestic 0 Industrial ❑Municipal Property Owner Name Christopher Van Ackeren 0 Dcwatcring 0 Irrigation 0 Test Well 0 Other Well Street Address 3810 SE Lynch Rd Construction Type: Method: City Shelton County Mason New well 0 Alteration 0 Driven CI Jetted 0 Cable Tool ❑Deepening 0 Other 0 Dug t❑r Air- 0 Mud-Rotary Tax Parcel No. 31902-43-90021 Dimensions: Diameter of boring 6 in.,to 96 ft_ Was a variance approved for this well? 0 Ycs E No Depth of completed well 96 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p 1VWM or 0 EWM O I ❑ 6 in 0 92 0.25 in. l I 0 El 0 Location(sec instructions on page 2): [l I ❑ in. _ ___ __in. ❑ 1 ❑ 0 I 0 SW '/.-'/.of tltc SE ''A;Section 2 Township 19N Range 3W ❑ I ❑ in. _ ! in. ❑ I ❑ ❑ I ❑ Latitude(Example:47.12345) 47.15961 ❑ I 0 in. in. ❑ I ❑ ❑ I ❑ Longitude(Example:-120.12345) -123.020003 Perforations: ❑Ycs O No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations in.by__in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft.to IL below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: III Yes 0 No Q K-Packer ' Depth 90 it information. Use additional sheets if occessaty. Manufacturer's Name Alloy Machine Works Material From To Type Wire wrapped Model No.Diameter 5" Slot size.016 iu Brown gravelly slit,tight 0.from 91 n.to 96 ft. 9 9 Brown gravel,fine sand,dry Diameter Slot size in.from ft.to_II. 14 Brown gravelly line sand,silt bound,dry 14 21 Sand/Filter pack:0 Yes C3 No Size of pack material is Brown gravel,sill,dry 21 28 Materials placed frotn ft.to n. Brown fine sandy gravel,silty,dry 28 42 Surface Seal: 10 Yes ❑No To what depth? 19 ft. Black fine to medium sand gravel,gray silt 42 a Material used in seal Bentonite chips binding,cemented,dry 44 Did any strata contain unusable water? ❑Yes ❑No Black gravelly gray clay,hard,dry 44 52 Type of water? Depth of strata Black fine to medium sandy gravel,silty,dry 52 68 Method of sealing strata off Brown small gravelly fine sand,moist,tight 68 T 74 Pump: Manufacturer's Name Type: _ fine sand,wet,loose 74 81 H.P. Pump intake depth: R. Designed now rate: gpm Black gravelly medium sand,heaving,water 81 96 Water Levels: Lend-surface elevation above steno sea level____A. Gray Clay,stiff,dry 96 96 Stick-up of top of well casing 1 ft.above ground surface Static water level 42 ft.below top of well casing Date 12/10/21 Artesian pressure___lbs.per square inch Date - ----- Artcsian water is controlled by (cap,valve,etc.) _---- -- Well'rests: Was a pumping test performed? rO No 0 Yes '==> by whom? _ Yield gpm with_It.drawdown after hrs Yield gpnr with_0.drawdown sttcr hrs Yield gpm with n.drawdown niter hrs. Recovery data(time=zero when pump is turned off-water level measured from well top to water level) -_- Time Water I evel Time Water level Time Water I.uvel Date of pumping test Bailer test gnus with_ft.drawdown after hrs. Air test 20 gpm with stem set at 8 ft.for 1hrs. Date 12/10/21 Artesian flow gpm Temperature of water 51 °F Was a chemical analysis made? 0 Yes ICJ No Start Date 12/10/21 Completed Date 12/10/21 WV11,L CONSTRUCt'ION CERTIGICA'I'rON: !constructed undior accept responsibility for construction of this well,and its compliance with all Washington well eonstntction standards.Materials used and the information reported above are true to nay best knowledge and belief 1,71 Driller Li Trainee 0 l E'-Print Name Roger Phyllilan _ - Drilling Company Arcadia Drilling Inc. Signature 1�� —' Address PO Box 1790 -- License No.2053" f City,State,Zip Shelton,WA 98584 IF'TRAINEE:Sponsbr's License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Dale 12/10/21 ECY 050•1-20(Rev 09/I S) If you need this document in an alternate format.please call the Water Resources Program at 360.407-6372. Persons with?rearing loss cast call 711 for ll'ashington Relay Service. Persons with a speech disability can call 877.333.6 341. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Christopher Van Ackeren Well Tag#: ALN049 Phone: 541-913-0950 Depth: 96' Well Site Address: 381 SE Lynch Rd., Shelton Pump Set: 95' Date of Test: 12/13/2021 Static: 40.7 TIME GPM LEVEL RECOVERY 1 Min 2 41.6 TIME LEVEL 2 Min 2 42.5 1 Min 50 3 Min 8• 45 2 Min 46.5 4 Min 8• 47.2 3 Min 45 5 Min 8 • 48.5 4 Min 43.7 6 Min 8 49.1 5 Min 43.1 7 Min 8 49.5 6 Min 42.7 8 Min 8 49.7 7 Min 42.5 9 Min 8 49.9 8 Min 42.2 10 Min 8 50 9 Min 42.1 15 Min 8 50.3 10 Min 42.1 20 Min 8 50.7 25 Min 8 50.9 30 Min 13 51.5 35 Min 13 56.5 40 Min 13 57 45 Min 13 57.2 • • Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANGUAR Report of Laboratory Analysis LABORATORY ` Collected by: Chris Van Ackeren Matrix Drinking Water 541-913-0950 Laboratory ID: V240301-10 Sampling Address: Date Sampled: 3/1/24 13:45 60 SE Sells Dr Date Received: 3/1/24 16:00 Shelton,WA 98584 Date Reported: 3/4/2024 Sample ID: 60 SE Sells Dr Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V240301-10 Analyst:VJ Coliform,Total Negative I 1 MPN/100 mL 1 3/1/24 16:40 E.coli Negative 1 1 MPN/100 mL 1 3/1/24 16:40 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Robert Smalling,Chemist on 03/04/2024 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 03/04/2024 DF:Dilution Factor girl. 17025:2017 MCL:Maximum Contaminant Level S`i� Page 1 of 1 Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com W E-2- 6 z,4 - O bo t, 3 2208095 MASON CO WA 02/29/2024 03:46 PM NOTCE 111111111111111411111111111111 II I IIIII IIIIIII III IIII IIIII IIII IIII2 Return To ej 8 L�: tr�. `C- ‘ MAR 66) 2 8 4024 Grantor(s): (1) eir 6 44r f Y(2) JciA/ Grantee(s): (1) PUBLIC Legal Description (1) LOT1 OF SP #3009 AF #1902998 PTN W1/2 SE (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 31902-43-90021 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) 31902-43-90021 Tax Parcel: (Connection 2) WA The system owner is responsible for keeping this system in compliance. The name of the water system is: � r-7c cML' 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 o26 day of 0-'E2? , 202V . Signature of for ): (1) , (2) x} 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 QLa ay of P'e oc-kickl\. , 2024 , C �n r 5 Va.,n (�c.1�e.r�� personalty appeared before me, who is known to be signer of the above instrument, and acknowledged that (she)he (they) signed it. GIVEN under my hand and official seal the day and xear last above written. """" Notary Public inand forte State of Washington, RMR o,,,,' residing at 5 �-� v1R /F 700% s My commission expires: 1 / 1 1 NarARy, m G tiy 2 = ..mod .tio Q, ``,,,,uuiNldN Page 2 of 2 V min r�o--c)K \\ ' i:yi r e 9... • w. °° pry , 5c[i1C:7. ii`,--_. ..\\ \\ h , // / A r • i • 1 -\\ t .r-,1-....., 1 N T fm / i m lJ z:, 1 N c. -i.. "` I P int- • : - ' ason ,e.., Printed from Mason County DMS