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Home My WebLink AboutWEL2024-00043 - WEL Application, Design, Letter - 10/15/2024 (2) SHELTON,WA 584 MASON COUNTY 415N6THELTON: , 0427-97 ,EXT 400 SHELTON:360-2754467,EXT 400 BELFAIR:360-275-0467,EXT 400 Public Health & Human Services ELMA.360482-5268,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 I Z/�l?Oz� UWE OCT 15 2024 MASON CO COMMUNITYSmRa Nl/(��(�a 5"Z RwrervWB PuY64Rnnn0.EmimmeNelNsltlu(emm�lM1NedN W 59s 415 N.6'"Stree4 Bldg 8)—Shelton,WA 98584 WEL Skit.: 360427-9670 AW Belfair:3W-2954469 AD0 Elms.360482->.69 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION MPIK/iNT PMpXE dwa{er Info ties LLC ZS •q4l 5ko3y MRlE1p a00RE8s-6Tr1FFr.LRY.6TRTq DP Zz g 5s ' Tacoma wa , q64 S an POpRF� �8-STREET.CnY.6raT LP Litj \(\V' PMMRYY7R1 7 EtO o LA SEco IA2--\ -b2. - 3\, OCO—1(] Is III I PPRLEL 11A'7E PPRC8L3L0TWEE ONew ❑Existing [i Vell ❑Spring c.cx e a-cfQ PROPOSED WRTERSYSTEM WIMEtREOUIREOI or PROJECT DEBLWPTION Q `Pt?x (\ e t)kq FX 11i CIl."�O SP"fUG(L�C7 v u��dv'&tCa ORIEeINNS TO Son?00NDITMI W Site Plan: (may also be attached) (property boundaries.structures,well site W100'radius.drivexays,roads,septlefsewer components and lines,easements,etc._) too `R tit 1 15�u GO&�-n m 1 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) Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of recorded document) 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: YES NO NA ❑ [� ❑ Evidence of existing sources of contamination within 1DO foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads within the 100 foDt Cadius of the water source?If so, is me priv to County or Slate. �-�,( What is distance to ROW? YYOO W ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? ❑ The well casing extends 1-above level ground/concrete slab?(circle one) ❑ ❑ Is there evidence of a surface seal? LO¢I 117.24f f ❑ ❑ Does the seal appear adequate? 4^41 ❑ 17 ❑ Is a variance necessary for well site approval? j�t RDF1� Comments 7 Y (4'Pass ❑ Fail Inspector Date ry IJ1.Zimy Review Step 2: Two-Party Review: NO NAIRS 1;60M (aCa taJr) C�fq() ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 7 Z !/W Driller 1 P 4 DR l GPM �S J ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test r ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Ili ❑ ❑ .System appears adequate to serve 2 single-family residences based on information pr �^ '(Comments ( ■. IYJ Approved ❑ Denied Reviewer Date [Finalls in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,express imd ofthe ju(ure success or failure ofthis systeWell site approval does rot constitute water system approval. Water System approval is a two-part process.losed connections to new wells are subject to water adequacy requirements at time ofbuilding permit per MCC ti.68. Water wage restrictions and additional fees may apply to all new wells drilledafter Jarmay 19e, 2018 per FSSB 609l. Revised: 10/132021 This form maybe scanned and available for public view on the Meson County Web site. page 2 of 2 WATER WELL REPORT DEPARTMENT Of Entire of Inner No. WE591300 ECOLOGY Dnpue Ecology Well ID Tag No BWi% Type onvmw: snare of wesnlrrgren a Sne WNl Name(ifmorethemomwell). ❑ Dewnu:dui® C OnlVmlimulktion NOl rvo. Water Right PPnnir/Cenifimle No. Propmed Use S Dommni, ❑Indmial ❑M+rkipi Pfaperty(Toner Name Ted Data ❑Cewddnp ❑nnpalnn ❑Tea Wall ❑odes well Streit Addres Beaf9 In eoaddra ioe Type: added: city �gpp county Mash 0 New well ❑Aberahm ❑Dr. O]epd ❑c::ble Toal ❑Deep., ❑Told, ❑Doe IN Ai,- ❑MrdRday Tu Pnrcel No. 42132-31-00080 Deaaslaw: Da:atmafbwln96 Pa.m 59 a Wanvediftedea,provedfmdisawll? OYa IBM Lbp:hafiempleadweD 59 d. ca.drdeeWr Demon: Wd If,,,what was tho vnience Rare Con, Limes Dooders, in:. To ransomed, Seel PVCWeked TNd 0 ❑ a in o 50 A in. 3 1 ❑ 0 1 ❑ l n,ando lard iasuucriwD an page 2): RWWMm❑EWM ❑ ❑ _ _ _n. ❑ 1 ❑ ❑ ❑ NE rail Y' kaft 92 Townsbp 21N RE,,; 4W ❑ 1 ❑ _ _ _m. ❑ I ❑ ❑ I ❑ Witlde(Examplc:47.12N5) 47.26298N ❑ 1 ❑ in. A ❑ 1 ❑ O ❑ LonBirude(Lemrnple:-120.12]43) -123.21806W pedwades ❑Yes ON. Typ.efpnfa+w reed Ddlkr'slug/Constraetion or Drcommiuloes Prooedare No.o(pe,fanriwn_ Suaofpedw+imw_®by_io. Federation Dewrih nywlor dresser in-ofmLed and on-lie atfte luWW Pdnmad Ram_A m_a.brew"wed anew wn.rare:v maendine::o klw peaerad,with dkan arse roes,for ear imago of sweem: 0Yes ❑No WKI'ahm b Doodb WIL inbrrmrun Ilwtlfwiamleads"ifnneuvy. Mw:rderr:wrs rvam.AIIDY Maldline W:TM Materid Frain To Type Wive diapped Model No. Eimom,Data 1p grp5igpa Ba raVC, M 0 INnrcre,5_ Soo 020 island ae_0-0 IT g Dirmewr_ skeeo[_in.9am _gm_8. hYdDain BlOom,flue te,nladm sal sand old val,bosa 8 14 SWPDer ado:❑Yin ON. Siwafpes.:ervid_in BrgyD fine to Reftalkarm Silly Wrd arM od"al,bp9e 14 Mebien flue!fwm_R.to_n. mobil 24 avf a.Sal: OTw ONa Tawl:admra? 18 6 BlfNAlflM eaM,fltlabnledklln lfeditdored 24 Meniel::W inW BBnIpM tlYpr coda.Wet DWarywameamm.assidebnwaeY! OYw ON. Tyleofwael! Degnof. MdFadofoolinpard—If Pomp: hl.nufxmm'a lame Tyye N.P._ fora,im,ke desK_a. 0..p:M Sw,+e:_Won Weerlevde: Lamnamf+eelevdionenowrre mkrel 30 6. Stekupofrwofwellw,u:e 2 fl.eMveprwNemdev Some wear kel 205 flnebwryo(well mr,g Did 7117124 Areas.Pwame_he"darere ircn Dde Arre,iw wean+ewwlW as (Ira-valve am.) Well T.: Was a pw,%No ofiandeft' MNo 0Yes ,-S by wMm? YnW_Wmwid_fl.dnweawn.der_he Yield_Wmwid_n.bawtlown eMr_M1n. Yidd_Wm wid Admwdo—aflm_M1n. "trrryeks'abe-rew whn Pu:rq is IumM oD weld kwl w:.W fimn well mpmwa:u knell time Waer revel Tirre Water l<rel Time Wide L.wl D+eorlienwrgled Bainrl<n_Spmwid_a.dwwdownaflw_M nir ca 15 Eanwidnaeud+40 aknl In. Dead,71172/ Anwun fire,_Wm Teos,sommeofwae, 52 ^F wmaehoniwlaalyeia o.h? 'Yeas ONo Step Dead 7/1724 Complied Due 711724 WELL CONSTRUMON CERTIFICATION: I croslnNtd aMlm eoxq repwaibility fprcmamdim of Ibis xell,aM its<pmpliaree wilM1 ell Weshingron well cmamuion sardit s Mam1a15uxd aN dadinfommtion mpmed above art true to my bat knowledge and belief ❑Drillu 12 Too.2 PE-ft JaMuan U fl C Arcadia DNang Inc. /f _ Addeess PO Bin 1]90 L' w. N 3 IT Cry StaN,Zip 31re8an WA 98584 IFTRAINEE.S sor's License No. 5 Cmrnetaf's S,drodar"S.,,rafteatims, Regarmon No ARCADD1098KI Dead 7/1724 ECY 050.1S0(Rw 09/18) II/ynu nwdfhix Mxnmwn In an allemalel nut plow roll flue Water Rrmamex Pmgmm at J60407-M72. Penms w06 baring lou inn mN JIIJrWndrirgfon Relay Beeler Persorm wifb vpeerh dimblllly ran mll8JJd73fi311. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Ted Dahm Well Tag#: BPF195 Site Address: Beargrass Lane, Shelton Depth: 59, Date of Test: 7/24/2024 Static: 21.5' Pump Set: 40' TIME GPM LEVEL 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 7.5 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 1 22.9 40 Min 15 1 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 MANAGEMENT 4 LABC)RAIY)Ii11.:S ,, .eu W M C.T•..-.,WA Yua+ mow COLIFORM BACTERIA ANALYSIS FORM —.._. pre 8enpM Coletled Time Samae CPunry I cl . m ON rw.a wm SreYm 1�PM'we earl ❑Gm A ❑GmpB Gmq Aand Gmw BBpMnn-PmAOe eoinWew edOw eFI81NUp(WFq..____ Sy Paton: , —s�•�TCZ1-F!_—_—_—_—_ i Day Pbere:l I��tl _ Ctl PMne:l_ f 1 ybraypblgbl Fi vna.bMnaaMeymll 6nac� = ark @agpc�,oC �llq. coM SAMPLE INFORMATION Bangp capecmG WNW rJ _ � - gapfiEl�'p�!�s+mde mNa6tl SMGei iMVu:tldna rnnmfnh: .L^(✓/.IOr .( I^ TTP.aleayL.le�eapraYa.rasampLaamnyyosialmglse«m_n ' � iRouiM;Oisurbunon SsngLa yVM� 2O Rapeet8awpla WPl --... Lthmnamtl Yee r.::Faro-em sM.^4e.umt aun '._I IJ!Eat9xNaY rwNnIZ:"rUt i ('eNn9P RefiM4� 104� FAa_. 1 ' G!:14 W~RWI Soarce SenatY I UnzUJW�Y mYYb aYb�l Jen I B ' r ❑hgpm WP'I I:IOTme A�1S'JTi.icSri .. _ QAesesemom IAPI a Sal.cs ort.lVl Ww'Sourta Vhpr SangM i[rvnmraioni i g � ❑E ❑Fwn ,. :. O yn cy..w b nwrw a.y ~ tA8 USE ONLY ORINKNIG WATER RESULTS L,Aa�B USE ONLY Unsauahcbry TaN CdOwm Reeent.!M � !�.etishacmry ' [l Exa mweer ❑En9:abmn I i ! BxIBIW U¢!uiW RaWHATubi COfAMm -_ . . ;1WM. ECM :t00m1. IIOW HPC___-. _.Jim. ' Lhpkoenamt sa!np.rawu.a: ❑TNTL ❑Sampbbo as " IYua Tamp G" _`�f �Aox�im9!�f ✓ oea �i81 "iFim ni.r>w:4an:i�5 .psnwr—..w..wln—+bw aZ�F-i 1R�iF17Fi—_ 2217053 MASON CO WA 18li5l"24 11 30 AM NOTM GOWWATER PROVERTIES LLG EQMSaO Rao Fee. S3 50 Pases 2 I IIIIII IIIII III III IIII III gill IIIIIII II 1111111111 Return To G0\4yb TeX _{(cNex-t\Zs (-Le- 037,2 6 St E ia(j:xm, 1oa • gglj`i S Grantor(s): (1)Cj06"kjVjojxl-hes LL.0 (2) CvlduxLAe( Pfopu1VSL LC. Grantee(s): (1) PUBLIC Legal Description (1) NI�2 (Abbievisted rorm:i.e. Pot, block,plat Orsectlon, township,range) Assessor's Tax Parcel: (1) 2 3 2 - ( - b o b 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 1) 2 L Tax Parcel: (Connection 2) y 2 k The system owner is responsible for,keeping this system in compliance.. The name of the water system is: 1"e-a-f, Gf CUSS wo_w 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 At/G 20-Zf Signature of Gr or(s): Page 1 of 2 State of Washington ) County of Masan ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this day of , 20�t , i 'A l.tc. QY;rv. 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 wri en. "w,Owh,hF � e"ANY BRU hhq. +� ;p•�oh ++... N ary Publi n-a r the State of Washington, +". �o+NOTARY°+,;;IS esiding 511 11en & gV5iN i 2pgpyt _ My co `sionexpires: K7- I'7-YI�I EN°v PUBLIC Page 2 of 2