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HomeMy WebLinkAboutWEL2024-00028 - WEL Application, Design, Letter - 6/4/2024 WA MASON COUNTY 915NBTHELTON: ,6427-N, ,EXT 4 SHELTON:360d2]- 7,EXT 400 4 BELFAIR:380-2]5146],EXT 400 Public Health & Human Services ELMA:360-4825269,EXT 400 FAX:360427-7787 RODERICK & NANCI LARUE 181 E Pacific Rdg SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00028 181 E Pacific Rdg 421251150010 The 2-party water system, Pdvete Well LaRue(4212511500101421251150010), 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@masonoountywa.gov Sincerely, David Anderson Environmental Health Specialist Mason County Environmental Health ���IZOZY, QRMASON COUNTY °"'° " COMMUNITY SERVICES N,IIB,yvu�..o,r�..:e,m..Mlxmmcamm.mnNmm 415 N.b'^SVwt,(Bldg B)—Shel[on,WA 96564 WEL Ap �--C/ o Shelton: M0427-9610 x4W Belfslr:360-2754467 x400 Elrn :360481-5269 x4W TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT O PHONE 1 L IMILINa AL REb GbT0.E T C O PO 5/) L ((VV SITE ADDRESS-STREEI,LITV,STATE,IIP e PN Y ARCELX aERIW LLSREI SEGO Y RRC LNUMBER In AINILKABLID WATERSOUR E SDURCETYPE P1IRCELI LOT E PARLELIIAT SQE ElNew IEzisting [XWell ❑Spring P PIIr(OaDW<TE SYSTEM NAME iU1RE 0) LahiAe- JECT OES PoPTION OIRECTIONSTO SRFJ CONLngNS Site Plan: (may also be attached) (property boundaries,stmctums,Well site w/100'radius,driv,mays,roads,septiclsewer wmporWnts And lines,easements,etc...) See ct LI 5 ,off R s pL� (� [� pdLD o JUN 0 4 2024 Illlllll Submittals Checklist: (these additional items will be required for approval) ® Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) LEJ 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) El Septic Records (additional locating requirements may apply if there is a lack of septic records on file) This fsmr 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: 14 �e YE� NO NA 51� Arfk— "b*/e/i I'll 010 'I ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields,tanks, buildings; indicate distance on plot plan) 00 ❑ ❑ Are there roads within the 100 foot radius of the water source?If so, is road pli9atg, County or State. What is distance to ROW? /t [� ❑ ❑ Does the ground slope away from the ter source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? �J ❑ ❑ Screened and vented? J ❑ The well casing extends 1 r1 above level ground/concrete slab? (circle one) 0 ❑ ❑ Is there evidence of a surface seal? L44 'ft--ZitgT ® ❑ ❑ Does the seal appear adequate? toot! _11.40$71 ❑ [2 ❑ Is a variance necessary for well site approval? FGy; 6Nyl f 9 Comments II1 Pass ❑ Fail Inspector Dale p P //Z/70ILI Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? e � ZO eft fol 60 1%4 ((Zuni 0 If NO, date of Capacity Test / z ,n t Driller 00107 GPM o ❑ ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test Zc'(. J ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN J ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer Date 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 orfailure 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 M water adequacy requirements at time ofbudding permit per MCC 6.68. Water usage restrictions andadditional fees may apply to all new wells d illedafter January 194, 1018 per FSSB 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 WATER WELL REPORT _ :OEPARrM2NT OF Nmm of latest No. l?&4s063 s- `i ECOLOGY U,g,e&aio,rWellMTn No 3NX11R Tymor W,,k: Ptr-Lea n1YM11Memn O Biu Well Neme(ifmaelhm eiu vrtll): cmmmbn O Decemeismoa Onpna imolleuon Nol xu. Witter RightPmniUCenilfeeu No. Pmpased Use a aic ❑htlem4l ❑M.". Property Owm Name TVMr&Maoist LaRue ❑Droves, Oh,ip,im 13mW,s oaq, WNI81ml Addrew 181Peeft Rldoe CaneeNaTfpm limm CRY SM1BnM COwIY Meson eoN mp 0Amsa4oe ol)r o Misused aGLle Taal Commas ❑Oar 0Dy MM oMo6RaaT Tax PeneaI N., 42125.11-MO dm ,ste ,_ r.flast A_se.m212 a wasi. eaWmwdfwthis,mtr OYm [am DaPaafoellpdae0211 L CerumYNTmi, wen Nyaa, a tea fiia bin w LLy Lsr Ditrer Olin Te 1[Y4m Ism P'2Cwaldle TYmd III 1 o a k D z1a gmk a 1 0 M l 0 Uenan(:eiamNwlaon).&e2k OWWMaa EIYM 0 I 0 _k _ _k a 100 I a NE_v.-Aadec N_u:Sauim 25 TowWp 21N Ryes 0 1 0 _n _k a 1 0 ❑ I ❑ 1 0 _k a 0 1 0 0 1 0 Initule(ample 47.12M5) 47.205605 Umit c(aumplc-120.12 15) 42%12M P —fi m, aYm MNO 161selpraWe,m1 DNller'e LaLICaltNne&tamDmWmPtmadve N—Fa ,iwaliam_ 3usfpeamlm_kq_k Fa,mmmc 0[rmbegmle,.elnrc.NmafmmWr.mr..daell:d.e p —ifim_Lm_LtaMtpomdrab amroermemmavlbmA U-- OYm MNo aL4'adm C Dyk_a bkmb;na Um LLlmW Attbifwmlaiaabms�liesbaasial Mmak`mvleMme Mmel Finn To Tpp smdL 4 roman_ sblNm_ceam _!m_0. Brawls bam boa 0 5 P>mae,_ sm,�_i.dem _!a_L &own silly ewb& psasal $ 48 SasaMkil .a OYe Mm 9ivofpr1 sasl_k &OMIW seM& rit Mne:ia4 plecal dvm_Lm_n 9ta l silly selM&grareal 8] GD Ssrtnn SW: MYm ON. Taaiad.W IS -0. tl ity Marcnd and m ai owspr is CRbs &.silly dw 06 103 Ditl cm so-n emui.mmbbnarl OYa ONO Mu61mIp1pJ emElMa to msrse GavT 1W '1yPeotw.ron Da0a Mrtm aMtl boss "W 114 MOUW ofmmM muse &ownaty ismr,a gavall 114 In nmv. MmarenxJr xam TYp: CNay WRY dw 120 131 GM x.e_ vmvbm.a.pn:_a oaiW.d Bow,ar_wm N aem& revel 131 145 wN &own Ift ewal& ISeaI 146 162 WMmexea:�.lamimesas.®eamkal sun Glass,WRY emm& revel wet 162 I" mw.moOovaw.namb4 t lain.Wesa•suer MlMkabled M,0m boron 1BA s,auc wa..l..el eCe Lllosem etwRevip Date 2 nmbn weaee_ae.ms4mames Dam_ 1a gae,imwnN,i.ao�momq Ibp.Nmb>) MInlMablea bav410mmnlsOFLn m10 101 aV lTea: Imse wew 211 winvmpme,mpevmeep MNo OY. gwkea! • 211 212 YMd_Wmwi,h_LL Mwdnwn,&,_kn Yield_mu wia_a aaxdawO aM_last. L e,.wwmw..M_bti Raowp tl,p ninr-movhmpq beaxtloR-mk,knl imweE fmo,wn T— hr hwD Timew Weereerel Tin Wmm Leal Tim Wna heal Me ofpuoPiry W bib a a_wmwA_aM1awdeweJa La ,U,Im 20 win wakemme 2�(J_l6,=be. Din M82O21 Aauw , Tmipaeuusveotweur 50 •P WuaA®iW arysbaeml oYr MHe Seats Date 6e&'2021 CanpINN Dau Mul WELL CONBfRUMON CERTIFICATION: I mnmueetl MWwso:eq sammitllity fweotimsu m ofthis wall,W its mmplbin with all WelhiVan wall conalmm.Mae .Menial,uaM W the infamttidn re caeW sbwe ere tine a in,bm kmwlalge and belief. E Driller a Twine 0 PS-l?m1 H.JOM 62ge Uilliat Com en,Nmtlie WIN Ira. Supiesture &Iakm PO Dox 17M U.N..N74 CTIY.Suu,Zip 3nelbe,WA 00604 IF TRAWM:Spensw's License No. Canllecla'e Spmmr's Sigepee &Lbualiaa Nw ARCA OI086K1 Due M1YJM1 ECYM(al-20(liea M116) pima xaM Ndadecumnlman nlumae)wmaf plains m111MWarer Rewurcee Program m 36 034-023. Ptnau veld ManRq bu inn roil pll/or lVadinBron RekYSerNpe. Penomeilh aapeech G,wMllry mn caN8VV8336 41. Arcadia Drilling Inc. 14 P.O. Box 1790 Shelton,WA.98584 Customer:Tyler 8 Nicole LaRue Well Tag#: BN%118 Phone: 360-490-2516 Depth: 21V Well Site Address:181 E Pacific Ridge, Shelton Pump Set: 200' Date o1 Test:6-16-2021 Static:166.5' TIME GPM LEVEL RECOVERY 1 Min 12 167.5 TIME I LEVEL 2 Min 12 167.6 11 Min 168.7 3 Min 12 167.6 4 Min 12 167.65 5 Min 12 167.7 6 Min 12 167.7 7 Min 12 167.7 8 Min 12 167.7 9 Min 12 167.7 10 Min 12 167.7 15 Min 18.6 167.7 20 Min 1 16.6 187.9 25 16.6 67.9 30 Min 6 68 35 Min 40 Min 17.6 it 45 Mn 17.6 168.1 50 Min 17.6 168A 5 Min 55 n 17.6 168.1 1ir 17.6 i6Pt i ,L Thurston County Environmental Health + 412 Lilly Rd NE 1 Olympia,WA 98506 360867-2631 is TapmmON cotm�r COLIFORM BACTERIA ANALYSIS Oak Sample Calleded Time Sample County Cdbckd r. w Type of water Syekm(check only ae box) ❑ pdre .N . ❑Soup A ❑Group B Me All GroupAand GmupBSyekms-Prmdefmm Water adlltiealnvantary(WFly: System Name: Contact Parson: %( .' 0 Dey Rae.I ) CaIl Ptwe:�h(. i Smell: f`S n L (fly Em.Phone:( ) ' awdmadu 6x,IDva Ieina.edpnse anti t+a meY emmvl q i SAMPLE INFORMATION Sample cotiecled Mlnae): X Lt d. Y4+I4 i Spedfro m addraeaVhw[sample cptardt : SReplel or ' '.el . �'il Ll �re K.`'�a� �1,' rlj i� tT P n11 1 k •�t ii6.5� Type of Sample(Not droll only ono bar of#1 lhmugh#4listed bebw) 1.❑Routine Distill Sample ¢peat Sample(after U lt.routine) Chlmiekd:Yee_No_ ❑Diokbution Syatwl Chbde Residual:Total_I'me_ Chbdekd:Yee_No7L 3.Raw Water Source Sample Chbdne Residual;Total Free_ ❑E.mg-GWR(AR) I - ❑Facal-mna.pm,:ynrevlma.arW /UUnsatiele/c'lo mutkm tab �nual Raemd:Ye—Na_ Q2-+- - �ab�TT — ❑AmearantWriadg(AT) Unaatlafada7 routine mikdstak' ❑Dtlrer �TJ�I ]I S #.❑Sample Collected for Information Only i Investigative_ Coehuctionf Repair_ 0tiwr_ rLA13USE ONLY DRINKING WATER RESULTS LA SE ONLYtlekdory Total Culilolm PSettle resedend NCcteE.cng pmaenl ❑E.N.1teentmenl Sample Required:mple ko ol(>30 hour) ❑TNTCnagymm Colilo I100m1 Entalomctl NW mI. 1 Metiwd Cede: SM 92239 ❑SM 9222O 7 rdT�}p�F� ❑SM9215B, ❑En,okd® IO Date and Tme Nmarmd: ♦`/- I �° Z $ample1ww1 real nuevNaamawYel tab Dw Ody: 0 6 0 31yQ 2211584 MASON CO WA 06/04/2024 09,42 AM NOTCE 'AS ON COUNTY COMMUNITY SERVICES #198110 Rec Fee'. $304.50 Pages 2 Return To masonIF) 44 /nmmq St.1 Ser�l[Ce s' -S�F Grantor(s): (1) I�)nr�P.vIP.JG A G , (2) NWGN kARue- Grantee(s): (1)PUBLIC r� Legal Description (1)� 5 _ y(Abbi5viated fo . r.e.lot, Wock,plat orsodUon, towlh—ip,—range) Assessor's Tax Parcel: (1)k I a-—t--—L--ol&0--L 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 l) ��C� --LL-S— 51.E— Tax Parcel: (Connection 2) LL�L�-,L_-A-L 5— L© 1 /^a The system owner is responsible for keeping this system in compliance. n The name of the water system is: W r 1\�( k W- I I 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 speck provisions of the regulations. Dated on this Z—day of _, 20Z�6L Signature f G or(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 certify that on this 5rcA day of 'fwrv- , 2%PA bla�cy .4, Qodra y Ln C� personally 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 yea ast above written. H,II BRU,"• %, a"a V BRUyy,"•", ;" NOTARY�P•^N, otary P UA, i�LmyVA ate of Washington, re *din t cmS j!N 209271 ? ? My missionexpires: Q7-17-Al2 u�; PUBLIC p� •pMy,W Y�:MM I j 1 i 1 1 1 1I 1 1 i i 1 1 Page 2 of 2 I 1 ��o1or��/ 11�11 38579 Sys' NEB yg' SNo L , Oka Yicl 1 " r � uo n a a q 55y+ N 1 , sr. rJ,Pr talc: l"= coo 1 3o bo ao +�a �U` )rtN co rarc,�l sF�'{7.\1rJ'II-5 a / POtO o. Well \%�� lOzvjpprim0.r dral4if-4 beds 3 with lo,Y3o' rGS�rv� bGdS © Audio-VMMI Alarm \� © 0-=ut 1200 QHioa Septic Teak "C'/C Effiueatt wlt2t 3 Vo G Um PUMP ammber d APPROVED 4 VAOLA JOY JOnN50N't p, NOV O 4 LYGZ + � MASONGOUNTYENVIRONMENTALHEAUI cm -282z. RE?