HomeMy WebLinkAboutWEL2025-00002 - WEL Application, Design, Letter - 1/9/2025 SM
MASON COUNTY 415N BTHELTON:30427-97 ,EXT 400
BHELTON:380-02]-9fi]0,EXT 400
aELFAIR:360-275-0 67,EXT 400
Public Health & Human Services ELMA:360 82-5269,EXT 400
FAX 360427-7787
MCGRATH GALE B
430 SE BREWER RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2025.00002
430 SE Brewer Rd
319083200000
The 2-party water system, Rocky Acres (319083200000/319083200040), 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 COUNTY a a5
COMMUNITY SERVICES R n Kr 1^ R m e
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TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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Site Plan: (may also be attached)
(property boundaries,strudures,well site wit Go radius,driveways,leads,septidsewer components and lines,water lima,property easements,eu.)
5FF- �A} AC)chec -
Required Submittals Checklist: (additional information located on the first page of this packet)
XJqu Satisfactory bacteriological test from within the last year(this may be defamed if the well has not been drilled yet)
Well log and/or capacity test performed by a well driller(this may be deferred if the well has not been drilled yet)
I otice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
"is form may be scanned and available for Public view on the Meson County Web she. Revised: 1D172024
Page 1 of 2 //
---'-- Staff Use Only
Review Step l: Well Site Inspection: [...yyy!yyq/2 CP / 1�sdon
YES NO NA vwl 4W ,
�. ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(dminfelds,tanks, buildings; indicate distance on plot plan) //�s
❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road 119 ,County or State.
What is distance to ROW? � l..//
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
g] ❑ ❑ Is the well cap satisfactory?
QfJ ❑ ❑ Screened and vented? Old rlro
❑ The Well casing extends ! above level ground/concrete slab?(circle one)
❑ ❑ Is there evidence of a surface seal? Lat: 11. POO
r ❑ ❑ Does the seal appear adequate? Lon: -113.01410
❑ /I~J(,1/ ❑ Is a variance necessary for well site approval? Tag:
LLLComments
Pass ❑ Fail Inspector Dale / Zf
Review Step 2: Two•parry,Review:
YES N NA
❑ ❑ Water Well Report with adequate pump test on file?
If NO,date of Capacity Test Driller. 11 GPM S 6 �Sl rat Weir,
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test w
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN Z0�Z /SLR
❑ ❑ System appears adequate to serve 2 single-family residences based on information provideL7-�
Comments sOy� `FO 0y Approved ❑ Denied Reviewer Date Z
Ty
Findings in this review reflect observedcorditiom as they existed on the day ofthe site inspection. No claim is made,espress
or implied ofthe fulure success orfailure ofthis system. Well site approval does not constitute water system approval Water
System approval is a two-part process.
All proposed connections to how wells are subject to water adequacy requirements at time ofbuilding permit per MCC 6.68.
Water usage restrictions and addition/fees may apply to all new wells drilled after January 19i6 2018 per FSSB 6091.
— _ Revised: 12/17/2024
This form may be scanned and available for public view an the Mason County Web site. Page 2 of 2
MOERKE & SONS PUMP I-DRIL;LING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805
PUMP TEST
AMBER KNOTTS 9/17/2024
P.O BOX 282
TENINO, WA 98589
WELL SITE ADDRESS: 430 SE BREWER RD, SHELTON 98584
Pump Make & Model: Pump Set At:
Sounder Make & Model:
Make & Model: Measured in: GALLONS
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 0 123213 75'
1 15 123228 76'
2 14 123242 76'
3 16 123258 76'
4 15 123273 76'
5 14 123287 76'
6 15 123302 76'
7 16 123318 76'
8 14 123332 76'
9 16 123348 76'
10 15 123363 76'
15 15.2 123439 76'
20 15.6 123518 76'
25 15.6 123596 76'
30 15.6 123674 76'
35 15.6 123752 76'
40 15.8 123831 76'
45 15.6 123909 76'
50 16.2 123990 76'
55 15.2 124066 76'
SIGNATURE:
SONS PUMP AND DRILLING
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2220402 MASON CO WA
0110912025 03 49 PM WTCE
nCGR9Tn a205319 Rec Fee $304 60 Pages 2
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Return To
a he�fc/A- WA gi5504f
Grantor(s): (1)
Grantee(s): (1) PUBLIC
Legal Description (1) Y1131 bur soe�rlQ 1 �,3
(Abbreviated/orm:i.e. lot, b�plat orsection, township, range)
Assessor's Tax Parcel: (1)--------------------------------- �31`-1 U?�- 3�-O(XX)O
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)-3- --(-0- -- -- -----
Tax Parcel: (Connection 2)
The system owner is responsible for keepingthis system in compliance.
The name of the water system is:
This system is designed to provide for two as 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. tr�tv//��,, cc
Dated on this day of 20�
Si na re Grantor(s)
(2)
Page 1 of 2
State of Washington )
County of Mason )
I,the undersigned, V%ti Public in and for the above nam County and State, do hereby
A�1'
ce ih ton this ay pf 20
J ersonall appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she they)signed I.
GIVEN under my hand and official seal the day and ye at a wri n.
�•!�•ER. �+.y�
`••• a•'o" Erti �s ota is I to o r t f Washington.
2° o� NOTARY'•',;'•; ;1 siding at
23038428 ? '. My commission expires:
.•� PUBLIC rp3l
:n9jF•..ort..... �p`•at
••w�WASM,.+•
Page 2 of 2
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