HomeMy WebLinkAboutWEL2024-00047 - WEL Application, Design, Letter - 11/5/2024 MASON COUNTY 415NBSHELTON: 60H27-O70,EXT400
BHELTON:360-0Z7-9670,EXT 400
BELFAIR:360-278 67,EXT400
Public Health & Human Services ELMA:360-082-5269,EXT 400
FAX:360-427-7787
ZAKEM SHANE & CHRISTIE
723 SE SOMERS DRIVE
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2024-00047
723 SE Somers Or
220325100026
The 2-party water system, Shared Well (2203251000261220325100027), 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
1Z / Z / ZoZy
MASON COUNTY
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COMMUNITY SERVICES a0
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Shelmi 360-027-96iR1 x400 Bclysv:360-215-4467x400 Elm:360-082-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
OPPIIL,INT Q� PMONE _ a
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New ❑Existing pQ Well O Spring I A"Ir .Z
OPo9EO Wr5TER 8VBTEY [(gEOUR[D)
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PRMECTWeOEeCMPTION
DRECTOxe TOWWCOx TIONS
Site Plan:(may also be attached)
(propertyWundarios,Bwdums,vwllsWWlW'reelw,driw r,maM,sephdsswIrmmpmorts and inns,easements,etc...
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Submittals Cheokllst:(these additional items will be required for approval)
CZ Satisfactory Bacteriological sample(this may be deferred If well is not yet drilled)
I$ Well Log with pump test or 4-hour capacity test performed by driller(this may be defamed If wail is not yet drilled)
0 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 vlew,on the Mason Courrp Web late. Revised'. 10/132021
Page 1 of 2
_________________._.__.__________________ ---------Staff use Only__—----______—_—_.____._________—_____________
Review Step 1: Well Site Inspection: 9
�VN 2 / f
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfeldc,tanks, buildings; Indicate distance on plot plan)
❑ ❑ Are there roads within the 100 fgot radius of the water source?If so, is road nv County or State.
What is distance to ROW? "0 �
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? r•
❑ The well casing extends above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? 10i 47.1647
❑! ❑ Does the seal appear adequate? bnt -Izz.v6sl7
µJ ❑ Is a variance necessary for well site approval? r4� 8pr'gr
Comments
gd Pass ❑ Fail Inspector Date
Review Step 2: Two-Party Review:
yFS NO NA 2$1*1r'r00N
h
P!'S' ❑ ❑ Water Well Report with adequate pump test on file?AIpC�OGUG M 6fFl�{ a r (��0(1)
If NO, date of Capacity Test 6161144y Driller !I' OQ "Q A711Mf GPM 'O J
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Ztf�SS
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments �'4Sp Qn
r7�
`` zy
Approved ❑ Denied Reviewer Dale Z y?f
Findings in this review reflect observed conditions as they existed an the d yd'/le J*dnpeadm AbdW n trN%sb,a I
or implied ofthefuture success orfailum of this system. Well site apprmd4her r osmllb eelerlyeaw apprbwt Wake
System approval is a two-pmQlMre.
Al/proposed connections to new wells are subject to water adequacy rapplMstrm 6.68,
Water usage resinctions and addiaonal fees may apply to all new we4eiWsi�10'✓+ery/lei.�11i�w851®6691.
. . Rarie6 1dI1Q021
Thb Perm mry M ewnmd and evslbhle for public elenr on the Mason taM'fillib*F w 3 d>1
WATER WELL REPORT ULPARFMENI OF Nmiceoflntem No. WE55802
t� ECOLOGY UniqueF Ind WelllD"fng No. BPF186
Tymd Wwk: �Slale nl dV23Mnglan
❑. Comuctkn Site Weil Name(ifmom than one oel0:
❑ Iuromnmmrnc Dngivm i,,.mmdnn nh No Water Right PermanCioi0cate No
Proposed fern 9Domcric ❑Imlrmrial ❑hlardcipl Properlypenav Nome Shane Zakem
❑Freon-, ❑ton'... ❑ran well ❑Other
Well Street Address 723 SE Somers Dr
CNeodlnType: Method:
O Newo well ❑Almmtion ❑Driven ❑Joel ❑Cable l'vol City Shelton County Mds0p
❑Dm:-oima ❑Coder ❑Dug M Air ❑Mad-Ravy Tax Parcel No. 22032-51-0002V a4 VWNW#O 6MeF 4/ DO
Dimension: Diameter ofia-18 in 0 202 fl.
Ixpm ertanylncd wd119B q Waze wnance approvd for this well? ❑Yes O' No
Conan-de.Design: wait If yes,ohm was the variance 11 B
Cads Liver Diameter From To Thkk.. Ant PVC We" Ifimad
M 1 ❑ a in. 0 im .25 in 3 1 ❑ M I ❑ Lmatioo(see martian.,an page 3). 3WWM or❑EWM
❑ 1 ❑ _in —In. ❑ /.'/.
1 ❑ ❑ 1 ❑ SW ofthe W" %;Sortam 32 'Township 20N Range ZW
❑ 1 ❑ —in, in. ❑ 1 ❑ ❑ 1 ❑
❑ 1 ❑ _to _in. ❑ 1 ❑ ❑ I ❑ Wlwde(E mpl,47.12345) 47.16982N
I.rmgitwlc(Example'.-120.12345) -122.DB503 W
IkrlamNrns: ❑Ym 5No Ty-of-rfomansed —
No.afperromtian— S ofpol timv_in.by—in. Driller's IaWComlruction or lkrommiadon Proeedun
No f,dflan R.rat abelmw araudswhce From'— Wsco"color,elmxter.sue ofmmmialoctia-lm ft e.rM dw kind a
me,crier mmedml in rash min, n.toed.whh ml lamt amp f« ,wM1d,,,,.r
nr Seree : wyrr, ON. IBK-PNkm 1� Depth 188 q. irtionliam. J—ddniorelmor'.f.—ar,.
nlanufwmrer'a Name cloy MacMne Warta Material From To
Type Allre-wrapped Alodol No
Nammer IT SWr are 010 in.Ran 1 W a.an in R. Brown fine gravelly s11101nder 0 8
Dmnwmr_ 51rt mein.Fenn R.lo_R. Gray fine gravelly sift 6 19
Gray
SamNr b pN O Yer li So—f pwk memiel_m. pis
d/FR der 19 30
Alaarimh-lard son_R.m_A Brown at and d 30 39
Surnee seal: O Ye. ❑No T.M.demi 18 R Brown area re silly de 39 43
hlnledml meat in N.I BenlOnite Chios Gra RI der 43 47
Did,rom-nawn-mablrwmn' over ON.
Blue elm d 47 51
rypeorwemn Damn ofisons Green sticky day 51 59
slmaidofuahnawamo0 Brow rally clay 59 81
Gray fine anavelly silt 81 55
Pam,: ManvIiiinm:s Nnae Trte Brown Doe gravelly sand sift,mist 65 75
N.P._ Dorm imakn depth:_A. DmiDed now rem:—Dim Brown firm to metlium graini eand,low stack 76 90
Wakr Levels: Lod-stet eekwtionnbore me senlevel 75 1 Brown silty Sa0d 80 a9
Sock-up chop orwell mina 19 Rnbc%c wend rerun• Brown 0ne to medium sand.coloretl grarassinnoist 89 114
Amic maol—1 918 q_pelow lopofwal rnsin9 rate 58124
Arnie.-more tar.M mos-iieh Date_ Grayfloe to medium sit sand fave,bose,wH 114 143
Anton wumr is—trained 1, (rap,vdve,are Gray silty sand 143 161
Gray fine silly sand,mist,having 161 IN
Well Testa: Gray has to worge gravelly sand,heaArkitwateo IDS 202
WNapompinRUN-rkmod? Ii OYe, O bywhonC
Yield_amn with_R.drawdown aRer_hn.
Yield_mm with_fi.dmwdo ii afisr_hn.
Yield—gpm with_A dmwdown eflrr_h.
Recovery dNa Dine-on.when pump u mned om-Diner keel incini from well
m,townnkve)
Time Wake ln'el 'fine Wier Level Time Weser Lew)
Omeof tons,wg rear
aArlta r em2_5 gnpmw iwhi thre_R. too fi.f. 1 Ma.
In. Data 818124 '
Arran Flaw—eon
Teo-rmumofwner 52 -F War e<hemialanall'ismde? ❑Ya MN. Stan IbN BHI24 GmPlod lbte SR3Q1
W'F.LI.CONSTRUCTION'CERIIFICAI'ION: I connmad ad/or accept responsibility far cammrrmrim Mthie well,apJ Rx«mrPbmlce with all\\':mhingum unit
oonatt ion standards.Materials used and the information reported ahoc are true to my Item AnmiledW 411W wid
K Driller❑Trains❑PE-Print Name Cam Johnson ladling Comlmnc Arcadia Drilling too.
Samoa.. Add.PO Box 1790
LnernM No. 3441T CRy taw in Branson WA 98584
IF 1 RAINEE.S ewer's License No.205 Contract
S nvx's Si lmm6 Restoration N0 ARCADDI098R7 Dale 6161
ECY0504-201Rev09/I8) Ipmnnerd MU dmnnrmnf ix err naenmJef amf.Please[all@ell'aler Remuraea Pmamrx air 360-107h971
Prrsmrz vidrAmring loss mn mil 111fdr N'nslri18loo Relar Service. Peramunail a slaeerlr d(ovinhyeam cglla77433-6341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Shane Zakem Well Tag #: BPF186
Site Address: 723 SE Somers Dr, Shelton Depth: 199,
Date of Test: 6/18/2024 Static: 92'
Pump Set: 180'
TIME GPM LEVEL RECOVERY
1 Min T5 93 TIME LEVEL
2 Min 7.5 93.8 1 Min 92'
3 Min 7.5 93.8
4 Min 7.5 93.8
5 Min 10.5 93.8
6 Min 10.5 94.5
7 Min 10.5 94.5
8 Min 18.5 94.5
9 Min 18.5 95.8
10 Min 18.5 96
15 Min 18.5 96
20 Min 18.5 96
25 Min 18.5 96
30 Min 18.5 96
35 Min 18.5 96
40 Min 18.5 96
45 Min 18.5 96
50 Min 18.5 96
55 Min 18.5 96
1 Hr 18.5 96
1 Hr 10 Min 18.5 96
vanguard Laboratory
v2635 Parkmont Lane SW,Suite A
Olympia WA 98502
va"Stall 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dale Sample Coaalad Tvnesample county
08/22/2024 0 e ❑ . MASON
smo on rar — —fie"
Type of Water System uhed,Dory ore bm)
❑GroupA 0Gmup8 ■Dam
Gmup A and Gmup B Systems-Provide from Water Faftes I.mn y(WFI)
IN — — — — — —
SYsamName. SHANEZAKEM
Gonad Pemon.Arcadia Onlling.Inc
Day Pl (Ml) )4263395 Cel Phone:( I
Emil'. Ea.Phone.( I
Sam mWah IPanl Np Rate,alarms ad.proses ama)
aMla&rt ,1 Ilmpam ANDpnnga im,minpran
SAMPLE INFORMATION
Sample wW*by(name).SHAD
Speak acatan whero sample catected. Specalmsbuclioa or comerAs
723 SE Somers Dr. Shelton Counts Please
Type of Sample III eery one tape of wrote 1.aMS t Itlmugb 5 bebm)
f.0 RouGns DbMgAbn Semple(AIP) 2 0 Repeal Semple(AN)
ChWnatea.Yes_ Na__...._ Ilrom bsbituWn sYslan eanunsa Wuarol
Umetalm,"mutlw lab number
Chbnne Raduel.Total.,_Fina_
3.Gro�und�Water Rules� Source
Sample Umatsladory mualemlaclaate —
L=J—LJ
Chlommul Yea—No_
❑TmNemd(A�P) Chbnne Raaual:Total—Free_
0 Asaamenl(AP)
4. SUAeeeor GWl Raw Souma Water Sample(Enumemlon) ' -
DE.mu ❑Fecal smarw_. w_
5.®Sample cdN lo,Immmaeon DaI,.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑unsatisfactory roil Coeform Pmentend srleaapry
❑Ecoh pmsat ❑Ecohaaara
Badadal Density Rauh.Total Colamm n00m1. E.cdi 110dm,
Fecal CdAoim ItOdm. "PC Ita
RspaanrM Sample Required: ❑TNTC ❑Sable am old
❑ Sample Volume ❑DamepM Comea'er ❑ —.
DSe. ma Rxnvea La Releralu laantee
Rxei ITem C' M&MCola
7.0
D9e ftlo WWN UbU Uly
WHtu,snw
285-
2218055 MASON CO WA
1110512024 02:04 Or NOTOE
CHR6TIE S SHONE ZRKEM #203355 Rec Fee $304 50 Rages 2
III IIIII!IIIIIIIICI$IIIIIIIIIIIIIIIII1IIIIIIII!IIIIRI
Return To
Chf,TL C L A14AD ZA&M
723 Sa. S e,rs r.
inw IAIA gUS6"
Grantor(s): (1) S kane -tz-akern , (2) C In r ,St:e— :akm
Graraee(s): (1) PUBLIC
Legal Description (1) I D+ ZS d-Z(r -€ e+'ToitAn S-hor¢A �x-E•
(Abbreviated form:i.e.lot,block pat or section,township,range)
Assessor's Tax Parcel: (1)
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I CWe)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 2)____------__--
The system owner is responsible for keeping this system in compliance.
The name of the water system is:�=-t-1
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 �b day of 204
Signature of Grantor(s):
Page 1 of 2
Slate of Washington )
County of Mason )
I,the undersigned, a Notary Publie in antl for the above named County and State, do hereby
certify that on this t9_day of O afe,�' 20 M ,
'Jane 2asYevsl�C1,.:s11e Zi*ex11 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 year last above written. (^)
Notary Public in and for the State of Washington,
HDO MUM residing at StleNon, W P
Notary Public My commission expires: 8-2
State of Washington
Commission+`23021125
MY Comm.ExPires Aug 4,2027
Page 2 oft