HomeMy WebLinkAboutWEL2024-00017 - WEL Application, Design, Letter - 3/19/2024 MASON COUNTY /15 Nfi SHELTON:36HELT967 ,EXT 404
$H STREET,
,SHEL ON, EXT584
BELFAIR:360-2754467,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360427-7787
Warren Ireland
111 E Ireland Ct
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2024.00017
4491 E NORTH ISLAND DR
221251100010
The 2-party water system, North Island Water System (221251 10DO10/221251 100010), 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
q/ooZy
MASON COUNTY
COMMUNITY SERVICES
NIN^4 iV'nME,Ma„rc,W NN,ACemnnM'NeJ,F
415 N.6e STOK(Bldg a)-Shell.,WA 98594 WE 14.0 Zy .
Shehorr 360-4D.96M x400 aelfalr 360 Z16 7x400 Elrc 3604W-5 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATIO AR 1 61014
PtKXNA� M rr�_ z� 1�od"T s0 IMRING _Cr FI.0 ATE.11V •�_ W 90JU
SITE s �P[ G;1 "1`'' __ e n
&, GIFT SIAM DV
orb' V'tna Drive- , S r-40r) WA 'f'ff5Wq
p IT ARCELN BER LL
21 5- - 1
SEC NDA PARC AlCAB up
�2 .2�_ -0 0 O 10
W.TIRSTPRG, I PA � LILDT06E PARCEL2 LOT nZ
❑New Existing Well ❑Spring
PROPOSED WATER NAME REQUIRED
JECT DESCRIPTION
p E 10 TO CONO NS ,
a� e r ssi rid e. floril-h Island
Drive e 2 1a a bo e doss rom drire a
Site Plan: (may also be attached)
(property boundaries,a6DOWres,well silo TIFF radius,dmeways,roads,septlrlsmar canponents end lines,easements,eR...)
Sew ��iC�eb�°
Submittals Checklist: (these additional items will be required for approval)
q Satisfactory Bacteriological sample (this may be deferred if well Is not yet drilled)
qf 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)
µ4 Septic Records (additional locating requirements may apply t there Is a lack of septic records on file)
th4 and avaita8la farlaOlfc
�` �° t1n z �f° °�°ounty JM
----.-------staff Use Only ------------
-------------------I........I--------------------------
Review Step 1: Well Site Inspection: A- W
"^7rp
YES NO NA
� ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
l (drainfields,tanks,buildings; indicate distance on plot plan)
❑ lyt ❑ Are there roads within the 100 fool radius of the water source?If so, is road private, County or State.
Z° What is distance to ROW?
I}'I ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?(� yk.
❑ r ❑ Screened and vented? U tt
y
❑ The well casing extends above level ground ncrete lab? (circle one)
❑ ❑ Is there evidence of a surface seal? Laf/! 47.79419K
❑ ❑ Does the seal appear adequate? Lun; -f21.869N
❑ [71 ❑ Is a variance necessary for well site approval? �� �`r�Q�1: NCR•
Comments ONl@Ye Sf��VG__ a� Oe��+ LI/GIHLr�YAIIM l InOIUMI�-
�
Pass ❑ Fail Inspector / Date ZV20
1 .
Review Step 2: Two-Parry Review:
YES NO NA �I ddr6AFl ( fe(
❑ ❑ Water Well Report with adequate pump test on file?
(l/Zo2y Driller t �If� GPM 20
If NO,date of Capacity Test 21i �=pef�a:Z' ;
P. ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 2 Z z
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN_ Z2 IS36
rd ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
fZ-4J�L/ -K Date
ty Approved ❑ Denied Reviewer
Iry
/=11rater
::A===]
onditions as the}'existed on the dojo of the site inspection. No claim!s made.express
oJ'this s•stein. 11'e/1 site approval does not constitute tvraer'system approval. I Pater
Svstem approval is a ovo-la process buildingme of per ed ions to nou lfee. rnupoppl>'mallrrs are s;,b)eci to water 4r wells drilled gfe.'f/anuary19*, ?alBper E5'.5B 091 N
Revised: 10113/2021
This form may be scanned and available for public view on the Mason county web site. ty D
ti E a s 4+rs;' +eve M
M.
n"m tat�iaprlvomD>w"� WATER WELL REPORT
s.mnecon—o.ner.mp>
TNb mp>_DKnwa Door BTATi M NAllmi61Y1N Mvef No. .... ... ..__._.._
(1) OWNER: Nam._Robert.-Ireland_.,.__.__._____ At.4_ Sys ton Wash.
a-.Z-"
(2) LOCATION OF WELL: caunb.-_1lseon _.__.......�.BE....q.S1E__w sRZi_.r .x.
0. Sec. 25-21-2
Y
(3) PROPOSED USE' Dmslte� InauK.W ❑ YwldpY❑ (10) WELL LOG:
4Klatlm ❑ Tan Win ❑ My ❑y aMO MIG�x o/WYWYI.n eW "and
IM .vM?> Dax.•.mm�uW p! wen ataba p.wer..tae. a.t aad.aniry M .ae...af fer.elea
H (4) TYPE OF WORE: tv m.a WW(... xwrrmer. saDx To
N.rr wau YeNna: Dal ❑ raf.a ❑
M DaaDoaa ❑ Gba� OdvR❑ 0 10 r
e.eeemuaeaa❑ >❑ raw! (3 abet
C ..n.,r.d aaVel
0 ltl M clay 0
a (5) DIMNSIO[NN S: DbmKar a!wm_.__....._6..__.aoa 11 ll�x_
O D,U. ._.....1Y3——n, D.tae^!wmpYYe waa.._.i l'i�1t _
ugM@l water
(s) CONSTRUCTION DETAU&
E C..I g )wtaued: b___. ••m m. n,an C n.a
nrr.aea❑ ._.—•=am--n. in
PertonLLown You xa,
Tsp s'amo as aae-.
`p =,.aef.fae.aa la.tb- LL
M 6
opemaca e0 6 Y 6
µ screens:...Yoa xadfRk --
a
a!
�' .e._—em—ar.—n
Y
NGrad yseked: Yn r...e twat+ 11d "4
L nnnt „� vrelMln l
` spy
co $x[IeM soul: Y xv 1 —•1B
❑ Ban M
0 old .W at." -- -- uvYY wYf TY❑
0 T>D.a!w aan_._ ___._—a.DNA
0 Ye1Loa o!n.An(KfKa ad—
o (7) Yun1Po x�"�` �p�a ant vwx��
T (s) WATER LEVELS:
ELS:
psl.u< a.et _ _ txaw nap a ww ant.
A"... vra.vra —._.._._.—_.m.ear Rum tare
(O.1 wKetlan wear a antauaa y.____-_-cou—T- _
W
O (4) WELL TESTS. w w�.in.`lw.ati tx.exw
jm = b
C Wa...wnObKmaeef Yn❑
> x vrn.e>.manr...___.____._..
wute.d.aae-_JWrz.29- 7.B- .s_n2
e1 Ywe: .t al. am n. &..down altar era. WELL DRILLERS STATENMrM.
This e l wa o dr[Ued uncle,m<iourisdicUm and this report Is
true to the
Avconrr Na lama Wav u mn wpm pump Wmaa .m (wear lord
&.nand !mm w.0 top a water arm NAMS._B%IQ31-XUMA-&..$111La6-(k!'_—.._.._.._._.._.._.
Q TM.
wKW Gal Time w.tar LaWI ben. wwar r+at IPanon, em,ar nrpWKtna) (TM.mind
15BH. Dickinson St Shelton, Mash
van,«art-----.._..—_.__.. (signed)....._.._._ _ ...____.... ... ._.........
sm.e tat-30_.-ra>w..(m_1S-r.andwa w_1--ten
�s nro.rt
-.a _.W..tn.m ma11tl.n4aa xqf unease N0.. _..__...._._mta..._.-._�O�It•• �••2 Io-�_.
rime— roR unty DMa.
gcr mt•x
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Ruth Newton Well Tag p: None
Site Address: 4441 E North Island Dr,Shelton Depth: Unknown
Date of Test: 3/12f2024 Static: 125'
Pum SeI. 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 1 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 127A
9Min 20 127.5
30 Min 20 127.5
35 Min 20 127.6
40 Min 20 127.6 CUSTOMER
45 Min 20 127.6 Copv
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
Printed from Meson County DMS
412 Lilly Rd NE
Olympia, WA 98506 9
360 867-2631
THUPFrtaN COUNTY
` COUFORM BACTERIA ANALYSIS
Dam Sample Colli TYre Senpm c-*
gaol �� � moon
Tr8gfWabSyobm(dark0dy"box) ❑ PrbNe Nauxhold
❑GowA ❑GoupB Row
Gew Aend Crew BSya -pmeWetom WNWFacMat Wry(WFI):
IDo _ _ _ — - -
SydWnName:
Cadad Parem:
Day Phan:( I CON Phone:I -
Emi on M EtsPhNW:( 6D)y'Z6'Sl3
SWd nmN, Wddp oodem W,N N9Wa)
Or sa ril
e&n JAfA q'858
SAMPLE INFORMATION
Sempb In ):v�e�g1.._�nylq
4HH1 I�COWr'Yh��SSlaad �r eP°`�mWuaw+armmn""a
Typo o/Semple(muW dnW'A *am hoxof 01 Nrtuph W"'ad bebN1
1.WR.0 ne M.WWdon Semple 2.Repeat Sample(afkrun.L mutlne)
Chbnnamd.Yes_Now adnbuDon Syokm
Chbnne ReWual.ToW_Free_ Chb*,*d:YN-X—No_
d.Raa,Wamr Souma SaMPle Chinn Reddual:TOW_Fr:e_
❑E ci-GWR(W
❑Fecal-sum.om.aPrx.Inaaaal a UnwasWbry mulne lob number.
FYWnd Ym_N-_
❑Aeessvrent lbn4.np(AlP) Ursailidadorywne DDleddem:
Obftr _ _J—J—
S
4.17 SampleC 11ec d Torhdomnpon Ody
nneaepaare_ Conemx, IRepelre_ Man—
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UnSgdaolury TOW Cordorm Present and tlefed Caemded
❑Ecappreseol ❑E.me abeenl
Repkcemad Sempk Required:
❑Sampleboad(> )0 ns) ❑TNTC O
B.d rWDWl-VRewtt:Tgml COWNM /loom' E.mtl Man'
Fecal Cordorn /100m1 EnW1DW n00m1.
Memod Code: SM92238 O9109122D �aM�Taen�e {ODb
SM92158 - ❑Entm"
pie Wd TYreAmIWd: I'2 Dek pam I.Z
saaprw+r� iW,oveuawaaW WUea Ody
Prin _ R� ounty DMS
Refun To 2215369 MASON CO WA
091001402E 02017 PM NOTLE
\A)GArfr -- W\(1V\k RELRIN %201101 Rec Fie E306 50 Pa9es 2
IIIIII IIIIII III IIII IIIIIII IIIIII IIII IIIII IIII IIIII IIIIIII III IIIII IIIII IIII IIII
-r- \(-EY\c\ ClIwv
`.iho\� lnl►\ a1�5$�\
Sep
RF�Fi SZOI„
CFO
Grantor(s): (1) \n . (2) \r.1ClM-" TY&AO n�.
Grantee(s): (1) PUBLIC
Legal Description(1) -rVt2 re m plat or o� a, -\ Z
township. range)
Assessor's Tax Parcel: (1)2 Z —�-2—�--)L-L-QQQJ—�
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)�,
Tax Parcel: (Connection
The system owner is responsible for keeping this system in compliance.
The name of the water system is: S" \Q`f"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 day of Ag/�r, 20
SignattuJ/of Grantor(s): //� 7
(1)TiUIJ/Ltu '/ . (2),�^ i�L
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above narped County and State, do hereby
certify that on this day of 5?,Djg1nber, 20 ,
\AIWW I1Df6 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 Iyear
rllast
above written.
aNWuurnun OVA/` �.��
...on' AV ii;� Notary PubWc in and f9r a State of Wash% ington,
b�l "
j. residing at .r�7l�ull t{Lt S�' �{'7C� '�OV�
My commission expires: 9—YI—XZ7
NOTAgy Si; -
N Q3S p18LIG �:
gpi�f WASH,NG��p
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