HomeMy WebLinkAboutWEL2024-00043 - WEL Application, Design, Letter - 10/15/2024 MASON COUNTY 415N6THELTON: 0427-97 ,EXT 40
SH STREET,SHEL ON,WA EXT 400 BELFAIR:360-275-0 67,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360427-7787
GOLDWATER PROPERTIES LLC
15322 B St E
TACOMA, WA 98445
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00043
XXX W Bear Grass Ln
421323100060
The 2-party water system, Bear Grass Water System (421323100060/421323100070), 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
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MASON CO e�
COMMUNITY S a.m..a L Sy5 RVMMa.
aursnFl..,.wEioso�m.mlxmlN,r�..nlM1rA.lu ,(�
415 N.&Street,(Bldg x)-Shelton,WA 98584 WEL 102 pa)
Shelton: 3 427-96M x40a adfair.360-275d467 x400 Elma 360A82-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT w -heS LLC Plp�
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PRIRAPYV RLEL NUMBER fNELL91TE1 O �
a ECONDARY PA AFL NUMBER RF`RILASLE)
WATER III yJ2C l^'�c\••,, 10u oETYPE PARCEL I LOT SW PARLELSLOL Sa.E
ONew ❑Existing yvwell ❑Spring au e_g rj C.fXU
PROFOSE0 WATER SYSTEM NAMEtREAVIRED) ����( C
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Site Plan: (may also be attached)
(property boundarles,sbuclurea,well site w/100'radlus,driveways roads,seplir/se ever components and lines,easements,etc...)
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Illy 1 Q�ar Gr[�S I-n
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tagor -Ai—
Submittals Checklist: (these additional items will be required for approval)
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)
'gl Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of recorded document)
1p 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 or 2
-- ----—----------------Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water sou"?
k (drainfelds, tanks, buildings; indicate distance on plot plan)
rf ❑ ❑ Are there roads within the 10010 radius of the water source? If so, is roa priv to County or State.
What is distance to ROW? ``ffCC
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
�f ❑ ❑ Is the well cap satisfactory!
L�Qr ❑ ❑ Screened and vented?
❑ The well casing extends 1-above level ground i concrete slab?(circle one)
❑ ❑ Is there evidence of a surface seal? t0f] y?-z6Zf?
❑ ❑ Does the seal appear adequate? 1441 -/Z J,Z 11l0
❑ R ❑ Is a variance necessary for well site approval? T� ! 6 Pfl n
T J
Comments
IY Pass ❑ Fail Inspector Date
Review Step 2: Two-Party Review:
NO NA
❑ ❑ Water Well Report with adequate pumptest on file? Q�,,, �� iS6ol1 '�`60alrh] Cfmyd)
/// If NO, date of Capacity Test L {/&L Driller 11 D�GPM 1S
f ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test lOD
�s�s ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN Z I'M
f_ ❑ ❑ .System appears adequate to serve 2 single-family residences based on information p
Comments
?T—
40
le
Vj/ ry
Approved ❑ Denied Reviewer Date r'
Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express
or implied ofthe future success or failure of this system. Well site approval does not constitute water system approval. Water
System approval is a two-part process
w .
All proposed connections to ne wells are subject to water adequacy requirements at time ofbuidding permit per MCC 6.68,
Water usage restrictions and additionsil fees may apply to all new wells drilled after January 19°, 2018 per FSSB 6091.
___ --- Revised: 10/13/2021
l
This form may be scanned and available for public Hew on the Mason County Web site.
Page 2 of 2
WATER WELL REPORT DEFARf MENT Of Notice Iflnleal Na. WE56M
ECOLOGY ,o,m Ecology WeIIIDIq No BPFI95
T7Po aMoric stateof Washlaltm Siw Well Nam(ifmwe two me well):
M comm
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❑th waepd Cho'— ❑Ten Wen ❑alter Well So,,,Addrta Bastatireads L
Caubv -TaM: Method: City SheI1M Coanty Meson
M New well ❑Alralm ❑Driven Oland OCabb Toll
❑Dwpemy OO O oos O Ac O MOI.Raury Ta Parcel No. t2132-31-00060
plrwrlwoo I woww wpon,6 in.lo 59 1 Wed a var m:ce appmvd rot this well, El Ve, [a No
lJegM1of ..pmJwag 59 e. If yea,w5al. hvariance folr
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(Emplc12011345) 232 W
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WELL CONRfRUCFION CERTIFICATION: I crosl,uaad aMlm saxµ Isapwmlbilily forcansuaclim ofthu wNl,ald iw compliance with ell Wmhinglm xell
emwmaio,sd gwdS.MaweialS whoa dm1 the infmmwim mpmad above are Inge to my Mat 41wWadge and belief
❑Lothar IN Trainee❑PE-Print 2 o Johns. olloogComiti,Arcadia Drilling Inc
Sq,gu. Address PO Boa 1790
Li N. WIT City Said,Zip Shdlm WA 91366t
IF TRAINEE:R tai a Licme No. C...a
. S Reg aced.No ARCADD1091110 Dew 7/1724
ECYMJ-20(RdvN/18) l/}am needflrir Acrumenr in an alnmwe�w4pleaW cull dot R'afer Rewurte+Pmgnma]bW0)-0872.
Pe aam with heanrg lomm�all lllfar Wndlirgrwl Relay&rcltt. Pec vihayreandlanbility nmll871.833-6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA 98584
Customer: Ted Dahm Well Tag#: BPF195
Site Address: Beargmss Lane, Shelton Depth: 59,
Date of Test: 7/242024 Static: 21.5'
Pump Set: 40'
TIME GPM LEVEL I RECOVERY
1 Min 3 21.8 TIME LEVEL
2 Min 3 21.8 1 Min 21.5
3 Min 3 21.8
4 Min 3 21.8
5 Min 7.5 21.8
6 Min 7.5 22.1
7 Min 7.5 22.1
8 Min 7.5 22.1
9 Min T5 22.1
10 Min 15 22.1
15 Min 15 22.9
20 Min 15 22.9
25 Min 15 22.9
30 Min 15 22.9
35 Min 15 22.9
40 Min 15 22.9
45 Min 15 22.9
50 Min 15 22.9
55 Min 15 22.9
1 Hr 15 22.9
1 Hr 10 Min 15 22.9
I i MAlN i S
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= LABORAIX)RI I:Sun
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COLIFORM BACTERIA ANALYSIS FORM
Deb garyile�Time Sample Caanry 1
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SAMPLE INFORMATION i
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2217053 MASON CO WA
60SE LLOE L'TER PRWRTIEE t202590 Rao Fp: $0 50 Paaas. 2
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Return To
60\cause-( -{(LNex-tWc- (- e�
15322 6 St E
GraMoryal: (�)�� ��r°Perhes LLC , (2) �yld.cXiie ProQeH1CSL �
Grantee(s): (1) PUBLIC cc
Legal Description (1) N l/2 S1 N9 SO
(Abbreviatedform:i.e.lot, block,plat orsection, township,range)
Assessor's Tax Parcel: (1)q 2 3 2 _ 3 - b O b 0
� 31 -1Z1 - RA --
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) 2 L 3 z- 31_- O O �o O
Tax Parcel: (Connection 2) 2 k —�—) 2 - 3 - O V,U
The system owner is responsible for keeping this system in compliance.
The name of the water system is: 'De"ay Gf I�,SS WC Aex SySrQrv�
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_ 7 day of AV& , 20-ZY
Signature of G ���/ggqttt�or(s): —
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 day of Au°�, 20�t
t.e- Llw4^rn personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he he) (they) signed it.
GIVEN under my hand and official seal the day and year I above wn an.
BRU..,.., _
•�BION `�
164
N ary Publi a r the Stale of Washington,
;6?N °Nt �tOTARY _ esiding Shil♦*n l(� g4SF�1
209271 My co ossion expires: n-r-r"!-XQo-j
u+�.• PUBLIC
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Page 2 of 2