HomeMy WebLinkAboutWEL2024-00047 - WEL Application, Design, Letter - 11/5/2024 (2) MASON COUNTY 415NBTHELTON: 0427-97 ,EXT 400
SH STREET,
,SHEL ON,WA EXT 400
BELFAIR:360-275-0 67,EXT 400
Public Health & Human Services ELMA:360d82-5269,EXT 400
FAX:360427-7787
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 (220325100026/220325100027), 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,
fi //-i,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
IZ / z / 70?_ y
n MASON COUNTY °MWR IL -6 - d10�{ '
IiQgi COMMUNITY SERVICES «W a
,. ane.,9P.��a9r�mme+Ixwxxca,x�...�InN.lw
415 N.d Shen,(Bldg 8)-Sbdmn,WA98584 WEL U - ooc5q
Shelton: W427-%W x400 BeHs'm:360-2]5.446)x400 EIms:360-482.5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION -
MruuxT PNoxc
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MauxB aooscea-arREatt,�^a
oTE Mucet-araEer,ott,arn_TE],lale
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PRIMMY PPM10EL MIMBFR M'f LL tITFI
ao I-bonato
BECONDARYPa LN
ON UMBIR(IPMPxGYq
W TERlOMCE SIMME 11c PF.EL1 LOT taE PMCEL t LOTWE
1 New O Existing pQ Well 13 Spring
OKaE1e WATER(YTIM MEx1EOWMB)
Qr
PRWECT W EEICRI77N
e
DRECT0NBT0MEIC0NdT10m
Site Plan: (may also be attached)
1propedy buundenes,sbu9Nres,wall site 0100'rsdlus.ddr"ways,rosda saptld.r umponerdt and Enes,easemema,ek...
$d� SOMEy!arY
new < 0 6o rage yYp���
afr. Refit]82,94
�O
is hlo aSE SEfcW'-m-
S.
tS Se crows
SepE'1 c
wa+
Submithls Cheokllat:(these additional hems will be required for approval)
CZ Satisfactory Bacteriological sample(this may be deferred it well m not yet drilled)
CZ Well Log With pump test or 4-hour capacity test performed by driller(this may be defamed h wail is not yet drilled)
$1 Notice to Future Property Owners recording(record with Mason Co.Auditor,supply copy of recorded document)
❑ Septic Records(additional locating requirements may apply If Men its lack of septic records on file)
Thin form rosy be sunned and avollable for public view on the Mason easyrWA A& Revised: 10/13/2021
Page d of 2
---__-------------------._____________________________Staff use Only__-------___-___—________—_____.___________.___
Review Step 1: Well Site Inspection:
: F
YES NO NA �N'
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(c minfelds,tanks, buildings; indicate distance on plot plan)
❑ ❑ Are there roads within the 100 fyot radius of the water source? If so, is road riv ,County or Slate.
What is distance to ROW? e"30 '
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? Q+•
1 ❑ The well casing extends V above level ground I concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Ulf! 47. 1696F
❑ ❑ Does the seal appear adequate? f,0g1 -IE2.g5Q
❑ Is a variance necessary for well site approval? 7,45:
Comments
IIa Pass ❑ Fail Inspector Date fl
Review Step 2: Two-Party Review:
yF,S NO NA V06UyOe16/pW7- 2S6A&�40Nh�J9d(el
rPKt' ❑ ❑ Water Well Report with adequate pump test on fie?�pC,Q.OtILI . �1,�/ y p r-
If NO, date of Capacity Test 616/tat y Driller A l"4 ''n YI'1,1r1 GPM '0 J
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test /LL/78
❑ ❑ Received Signed,Notarized, and Recorded Notice? AFN Z f c®
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? *04
Comments �QsO 12
Approved [I Denied Reviewer
o.t. Z 2�
9�H
Findings in this review reflect observed rnndinons as they existed on the dry.JYte 30e.epenfax Nosirae b.n6e,wj71m FAl
or implied ofthefuture success arfailure ofthis system. Well site apprmd4fM taaasrraM.suneeraytses apprusal. Wwr
system approval is a two-parfpreprw.
Allpropased connections to new wells are subject to water adequacyregeps.Mtttrat des{# ak&W{pawltpnAiCC 6.60.
Water usage restrictions and additional fees may apply to all new w ilsdp"*&JmNWY!Y.20UPFES60609f.
NarueG tWI31 21
ThYferm may be wend and evalluble far public New en tee 10180011 fw111011111fib01L hoe tl d s
WATER WELL REPORT DEPAN I MINI 01 Nmiceoflmem No. M55602
�dI ECOLOGY leigm Ecology Well lD'rag No. BPF186
TyprofWor4: Slate of Washlnelen
IN Caeuneeon Site Well Name(if more than wic wel0.
❑ Oaonmri<°ian alp On,wil inuallnrim NO]No. Water Right PetmitWertifcvm No.
P ¢mil Una 0 Derwask ❑Irdearm.1 ❑Massasoit Progeny Owner Name Shane Zakem
❑pexntd:rp ❑Iual ❑Tee Well ❑Owen
Well Street Address 723 SE Battlers Dr
cpmwwoll Type: mallsod0Drive City Shelton Co Mason
0 Newwell ❑OtheAnimation ❑Orlmn Otatd ❑e'ublel'eol M
❑Ih<pmrnrg ❑ou:m ❑INrg o nk- ❑nl::d.Rm,ry 'rue rarest No. zz93z-sl-0oozltG P+6f/'{o (BMeF 1./ aF
Dlnmien: Oamew,arbonna 6 m,w 202 n. Wusavormuseepprovedfn,thisxell? ❑Yes IIENo
D'amins mplaedw<I1199 a
C°mlrmaaaaemlb: Wall Ifyca,,Aal was the immune F.0
Cairn) Liver Domineer From To 1hie4ma &.1 PVC W<Well ruevd
1 ❑ 6 in o 1ij— .25 in. M 1 ❑ M 1 ❑ Location few,instructions on page 2). (AWWM w❑EWM
❑ 1 ❑ _in. ❑ 1 ❑ ❑ ❑ SW /./afthe SW y,;Section 32 Township 20N Range ZW
❑ ❑ _in. _ _ _in. ❑ 1 ❑ ❑ I ❑
❑ 1 ❑ —in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example.47.12345) 47.16962 N
LonBitude(Ixsmple-..120.12345) -122.88503 W _
P<rknaaml Ova 11No Typeofperkeraoru°N Drlller'al.og/ComuueRon or Decommission Procedun
No.afperfmaiase_ Saeofpweerai a_in.by_m F..,,.. DMilles sae vlmuner,sie°oLamdpled nN[Ilm,mJlhe 4i:d end
rerknlW fiom_fl.10_a.below¢mud asome ,e°
esumn n:nedal ioeaahtole,pewmld,wivemlevel mu<nwy fa eaM1 cM1vng<o!
&ream: WYn ❑No �K-Picker t� D<pN 188 fl. nfrn n Uu vdNhoml slave eifw.<svn.
hlmurwlmer s No_ Alloy Machine VJaks Material From To
Type Wlfe-Wrewatl Model No.
Dmisme, s_ S4e eia.ote in.fat I" n,to tee fl. Browo Ana arawaiNly slANlncer 0 B
Kamer_ Slotsae_in.from _A.to_n. Gray fine mangy sill 6 19
Gray
SandlFaerpzeh:❑Yes WNo Size ofpwk mrmiel_in, iatlek dal 19 30
Brown peat and day 30 39
xl.ednle vlwd fm_n.m_n. Brown and gray silty day 39 43
eufan S<al: OYee ❑No TowMldopw? 18 It Gray siltv clay 43 47
matimi wed in and Be Witte Chips Blue sticky clay 47 51
Ddunyraauwwinummblasna ! OYes 1JNo
Typ<erwaen D<pM1 ofumu Gruen stielky day 51 59
hl<Ilwdofa.ling.mwee Brusin silty day 69 61
Gray Arm granaelth,sill 61
Pump: Mmmm,a< Tsw Brovm fine gravelly sand sill,moist 86 76
Dr._ fusipRrinp w.m tvke e<p11c_A. Dedgwd now lur_gpm Brown fate to madmin graMel.51afty san4laW static 76 80
W nerl<eeh: land e:ufw<aeralion vbr<:n e<o level 75 n. Brown silly sand 80 Be
Sini.urafwp ofw<Il coring 18 a ahm'e"am eruWa, &Own fine to medium sand.woretl anwei.mmint 89 114
San.wale,kiss 915 fl,bdowlnpofxell wring the OW4
Ames..,preame_lbs.pet Muslim hmh Lore_ Gray fine,to medium ail sandy raveLMmae.wel 143 161
Anahn wmet ie emtmlld to (<a,edW.m.) Grin,sit sand 113 1
Gray fine silly sand,wet,heavin 161 195
Wall Tata Gray Mu to worse granally sand,heaM .water 196 202
Wa•pumping lost Marooned? NNo ❑Yeses by wlnnr?
Yield_pate with_n.dawdown<ner_M1n.
Yield_Win with_a dnwdoxn slier_M1n.
Yield_pas avid,_It dnwdown lifter_lea
imoso ry des(lime=one when pump u.,it a0-water kvel:rcamed from well
wpm want kW0
T:m w9Rrl<ml T:- Valor Level Time WaerLm'el
Dee orpumpina e+t__
vmtw tat_Wm wish_ 160 n.fa
A dnwdw:n eft I—
me
Aw.. 25 p an.iweoms.. r 1 Ion. Lam M24
Anedsn new—am
Temrcrmu<arwn<, 52 •F Val-flro cal alYnhmad<p ❑Yes pNn Sven Ilse 6/4f24 Coullrtol Dal.• 68l24
WELL CONSIRUCTION CERTIFICATION: I cwsntacted mldlm accept resptmsibilay for construction allies sell,ad ds,,,mph:lnce%Wit all W'ashingaxl well
eur stmetlon standards.Materials load and the information repond slowly am true to my flea knowledge and MI Icr
❑e Under O Trainee❑PE-Print Name o Jollnwn Drilling t'oalpam Arwtlia Dvlli InInc.
Si tore Addrsv PO Box 1790
Limenee No. 3441T Cry Sure /ip$Meson WA 98584
IF TRAINEE.S onsor`s Limme No.205 Cloul r s
Sponsor'•Siputure Nee vat n N 1 ARCAM1096KI Late 6&24
ECYD50.630(Rzw09/IS) ffJou needrhld dxunum in nn nhernalefommr.Weme rnll th ll'ale,Resouryes l'rvgmm mJ60.f07.6672.
Persona u0h granng low rnw wll7/1fa lYnshOrgmn RelaJ'Senire. /'¢owls wirh<uPeerb Asabihry Cvn roll BlJAtibJdl.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Shane 2ekem Well Tag#: BPF186
Site Address: 723 SE Somers Dr, Shelton Depth: 199,
Date of Test: 6/1112024 Static: 92'
Pump Set: 16"
TIME GPM LEVEL RECOVERY
1 Min 7.5 93 TIME I 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
B 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 98
vanguam Latwratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
y,,,e,A!D 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dale Sample Cdledetl Time Sam Couny
08/22/2024 calemad 0 N MASON
am 0., rm
Type of Water System(check only ON boa)
OGroupA ❑Snoop B DMer
Group A am Gmup B Systene-Pmvide im,Wow Fed oes ImeMory(WFI)'.
tm - - - _ - -
SyslemNsme SHANE ZAKEM
COnW Person.Arcadia Dnlling.Inc
Day Rlone(360 )426-3395 Cee Pnos'.1 )
Emil I Eve.Phom ( )
Setl Imlh W(Pnnl adl lore.atliresa ale igmie w amal7
enw®.maaalemOwm u+O n+.®vmel.anma rem
SAMPLE INFORMATION
Santos cdleaad M(name) SHAD
Spedfic lo®5on vhme samWemllecWd SpecWlinbuclWm mcammenW.
723 SE Somers Dr, Shelton Counts Please
Tygat Sample(seled ony one type of sangle Imm types t thmugh 5 bebx)
1.O Roudme Dletribu0on Semple(AIP) 12 O Repel Sample luP)
ChOwted:Yes No___ Pmm dsptutnn syemnasmunsm md*
unsaneachy mubm lab number
ChbMe Res dual.Total__Free_
3.Ground Water RUM Source Semple Usatstac"roufinepilleddme'.
I��
Chw"ead.Yes-No_
❑Trggered lAlPl ChMne Rstlual:Total_Free_
❑Assssment INP)
4. SudacewrGVIR—SOu—MaINIhemple(Bnamaa") LI l
❑E cdi 11 Fecal wed rr_m--
5.0 Sanpe C II Al d Mwmahoe Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Usalnacrory Total Cddolm Present aM Atlsta"M
❑E cdi present ❑Ewh aieml
housil Derlehy,Rsuha.TOWI COIAOcn It00M. Ecd_ Iloam1.
Fecal Colilam I100ml WC—It ml.
Replacement Sample RINIUM: ❑TNTC OSamWe WOdd
❑ Sample Vdume ❑Damaged Cmsker ❑ —
Daa' .me Rece,en LNReMerca Nuumw 1S
R.s, ITem C' �
7.0
Wle Re,NdW WN Iaaohwy
DON L&Samgm
285-
2218055 MASON CO WA
11105f2024 02:04 PM NOTCE
CHRI:SriE & SHPNE ZPKEM 4203355 Rec Fee $304 50 Pages. 2
111111IIIN III IIII IIIIIII IBM IIII 111111111111111111111111111111111111
Return To
;�I2rs�;e d�VIdM Za,t'2�✓1
77,3
sh.el�Yh�, WA gd'S6
Grantor(s): (1) Skcne -Zake rn , (2) CL,ri5f,e FoK )i
Grantee(s): (1) PUBLIC
Legal Description (1) I o+ Z5 ',"'7 CP -&)e+ -TZ)4-hLn Shore'b F,'4.
(Abbreviated form:i.e.lot,block plat or section,township,range)
Assessor's Tax Parcel: (1) a 9 ate• 5L- OQ aL
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 waterto the following
parcels situated in Mason County, State of Washington; herein described:
Tax Parcel: (Connection 1) a a 0 - �L- O d O a
Tax Parcel: (Connection 2)_____-__-____—
The system owner is responsible for keeping
this system in compliance.
l
The name of the water system is:�i1 (
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. q
Dated on this Ib day of I 20�.
Signature of Grantor(s):
(1) (2)
Page 1 of 2
State of Washington )
County of Mason )
I,the undersigned, a Notary Public in antl forthe above named County and State, do hereby
certify that on this�`i _day of Oc�pbe�f 20
`6ne 7a Y,,^ (,L, 4Ne Z*em personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (she) (they) signed R.
GIVEN under my hand and official seal the day and year last above written.
Notary Public in and for the State of Washington,
NIM MUM residing at Stie.1AOn W A
Notary Public My commission expires: 8 2.7
State or Washington
Commlxion a 23021125
My Comm.Ezpires lmg a,2027
page 2 of2