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HomeMy WebLinkAboutWEL2025-00011 - WEL Application, Design, Letter - 2/10/2025 415 N 6TH STREET,SHELTON,WA 98584 MASON COUNTY SHELTON 360427-9670,EXT 400 BELFAIR:360-275L467,EXT 400 Public Health & Human Services ELMA:360-0825269,EXT 400 FAX:360427-7787 MACALEVY SCOTT & JACQUELINE 100 NORTHERN SKY DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2025-00011 100 E Northern Sky Or 421271190010 The 2-party water system, MACWATER(421271190010/421271190010), 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 360427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely, A-1 David Anderson Environmental Health Specialist Mason County Environmental Health Y�(S� ZozS" pge RB�.Iwa MASON COUNTY 02 / 2 0 COMMUNITY SERVICES mw RxN ,S Ra� Pu il8rq P6mvg FmvmmeM IMllh Camm,wRY IIedIM1 415N.6'"Soeet,(BIdg8)-Shdton,WA98584 WEL 21N'- SMltw 360-42M670 AW Belfair.W-275407 x400 Etna:360482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PHONE PPPLIC,LX�®-� Mw cfl Ltv `;? JO I —C1313 N MAIt1NLLACBRE88-SIREET.LrtY.BTPTRlIp O O (b oKrHI'�NSK BnE AnORE88-STREEr,CnT,STATE,ap m NOa-rrtt Z t1 TvN wP, 98S8y tyl PRIMARY PPRCEL XIIMBER IWFLL 9IIE) T 4Zt27 1i 9OOlo m SECOXBARYPARCEL NUMBER IIF APPLICPRLE) WATER SOURCE SOURCE TYPf PARCELr IAT 86E PRRCEL2LOTaNE ❑New JZExisting In Well ❑Spring s I°tG(t-0 S PROPOSED WATER SYSTEM NRME I0.EpU1REn) C PROJECT BEELRNTION I r p1 D F _[J� ` .ECTIOXSTOSVeC.,rrro C J/ 1T4�1�1L��T1 (S 1RT EMSV 44 WYbI N To oR-TF} ' NSICY DE- d'F Daive WAY ©1J THE ILL Site Plan: (may also be attached) (property boundaries,snsctues,well site w1100'mdim,driveways,roads,sepBr/sewar ca POM Ms Ond lines,easements,etc...) fRcPopTlc Nr � I rPyAST 0 • 1 V 5 J 5 gLwn' r(!rD �T e ( °n'eKr 1 B • .� 367 t- a GNEaN oI mw 344 9>y 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 Mnrrl may be scanned and available for public view on the Masan County Web site. Revised: 10/13/2021 Page 1 M 2 staff Use Only Review Step 1: Well Site Inspection: YES NO NA Tyr' ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius o�Me water source?n � '/t (drainfields,tanks, buildings;indicate distance on plot plan) Q�e Pe,,f W V(I�✓ (070 ❑ I$ ❑ Are there roads within a 100-foot radius of the water source? 7' Is the road Private, County,or Stale?(circle one) Distance to the road(s) ❑ ❑ Does the ground slope away from the water source site? cJ , J Drat &aq/C 5Or ❑ ❑ Satisfactory well cap? O ❑ ❑ Well cap screened and vented? r ❑ The well casing extends above level ground/concrete slab?(circle one) ❑ ❑ Evidence of a surface seal? Let: 4Z.2Q7 O6`f of ❑ ❑ Adequate surface seal? Lon: — (23• (V73O-t [I ElVariance necessary for well site approval? Tag: �/_�- Comments: t tkp j CpO 0 ._ � `��y/�� lSd P ss (�[ Fail Inspector Date 2, Review r I/r�� Review Step 2: Two-Party Review: YES NO NA ❑ Waterwell report(well log)with a concurrent capacity test? ❑ Nonconcument/separate capacity test? ��y� Capacity test information: Date (Z/ZTL7 07 DrillerL_W(dy� GPM 7 Duration(minutes) Co GPD f� ❑ El Satisfactory bacteriological analysis? Date of test / //Q/4-oz y rrr���(((''' ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN 2 Z p( ❑ ❑ The system appears adequate to serve two connections based on the m*lafion p V dad ;a20 Commands: yc04 4 l `-' Approved ❑ Denied Reviewer Data o 9f 7FIndingsn this review reflect observed conditions as they ettsted on the day ofthe site mapection. No claim is made. sslied ofthefume success or failure ofthis Mien Well sire approval does not constitute water system approvased connections to new wells are subject to water adequacy requirements at time ofbulldirtgp18Nper MCC 91 arusage restrictions and addirionalfees may apply to all mw wells drilled after January 194, 2018 per FSSB 6091. lievised:01/10/2025 This form may be scanned and made available for public viewing on the Mason County website. Page 2 M 2 CL WATER WELL REPORT FEB 01 Y008 dglMlAr" wpy-P MYY.7waq-ewe, 3"wer-anne, CURRENT NoWEg7g77 WBSIJWR[oi Rci NONuopinen . 1ftaSta LC N Conytluctim/Decanmlplon(Yin circle)amqj6Unique Ecolog Well= N EOlo gy i ❑ Construction M Decommission ORIGINAL INSTALLATION Water Right Penrit Me. EXEMPT WELL C Noticeo/Intent Number Pyopeny Owner Name SCOTf MACALEVY O pmposmusM ff Dmoeae p IM1.0.1 []M.nm,lnl Well Sheet Address STATE ROUTE 101 G gW.at Iniaati°n MITeMwell L3osNM, or— npF of woRla owner.nembemrwenlxmmerNnmwl City SHELTON County MASON ORmYeeinMee McAN: ❑�k Oaemmw JMM4 LocelionNE-1/4-1/4NE1/4 Sec27 Twn21N R4W on. Cl Cheek EgMExSIanA Dumne:ofwNl i,rc....11m R. Is,L I Still REQUIRED) WWAS p. GAe O er mw.0 a Lat Min/Sec et3NSTaucTlan oerAlls Lat/Long Lan Deg heats �' L 6 Due'.Re _ '.m149�_ fl. Long Deg Long Min/See IMMI.d O u,Imamm.a= oimn.flmn_ n.m_fl � Tan Palcel No.(Required) 421271190010 V PaHmatlpm: Ve • NP Fbnslim'.�.[dte EY cYlm,tliucla.rim armYenal and abuclY:S entl IAe kits mtl Q Ty{e ofpnf°,MmmN nrly;e°f lFe mekn.Imul,mason PaemlW.wah.l leea nw ml.Y fm md,dmsa 512E ofpeA_�N.Uy mwtl ro.ofPr.O_Rbe fl.m fl' ofinN:mmiM.(USE ADDITIONAL SHEETS If NECESSARY) W Srr•M: Ely. EN° C3K-Pw, 1AL'M1O° MATERIAL FROM TO MMYN]Yml NAM BROWN SILTY CLAY WITH GRAVEL AND 0 TAM ENO' COBBLES it f5ia Sle ern fi— A.m _R. BROWN SILTY SANDANDGRAVEL 21 n DNn. sAx.me flan R. e R BROWN SILT BEANO GRAVEL, = b.nUFNM I.MAYA (] Y. ©No Sim°fga.+Ilmntl TIGHT.COMPAC7 57 AAYetlely Nmed Rmn R.lo R BROWN SAND AND GRAVEL,WEf 57 93 AMNm3x1: DYe C] No Te M.leeu? 18—_n LARGE GRAVEL,SOME SAND,WATER 93 100 C Mmmi.ImmN wl BENTONITE CHIPS W aemnPm• •N YYembla wpeD ❑ve pa He V Tyye elwmw? D.Nh°rmM. MaNaEofsYingsmleon S PUMP.W:Wxrurera ro;na F Type: H P. O W.7. NFL5:la:Y1fa11MeeL+mlm ebwe:nnnsM lent fl. Z smelem158 n.blow mP efwen wm 1227/07 NAnmmvrrnure_IM,M,umMI.h Due Sterm.M.Mw Ialby 9 wfunsn:Dmwtlmwnlvmnmmw•cerswm lslexe,ed bekwnmclrm WmepmP M. ❑ ym N. Hrm.m w4mn? Yi4d. YM./rim:.wiA flA.we WftkR �An Y'Me._ IMAM..WA _fl.M1rveown eRa_M1la. O Yide. plFoin.WA fl.8vutl.wneM _hn () aec°wrytl�b UMemYmuawe xM1enpump m:rlMMRlwalerkYM mwrWeEM1Pnwep W teplewmml") a� Tme WYULm,M I— Wmw 1. 1 T.— W. I d op.enm 6.w — BnlerTm_sYAnin.wiA flNwneRm M1e. 1� Ama 20 y.Llnle.weM1 peer Mu f�R.Por 1_ _hn ,ra Aneim lNw__SP.m. om° Shut Dale l2/17/07 Cornpi ed Date 1227/D7 ampwYb°(wm_� Wa. AnnNmY s.m k" ❑ Ya QN F wELLCONSiRUCfIOR iERIIFIGTOMS IcansnunedanNm accept mspmmlblkyf m consouctkn ofehls weX.ard Its cemquntt wlA all WasMns[onwall mlmmmion slaMarm.Mawnala mm0 IV mfmmatior eporkd above art I.mmy New,Umwledge ant belief. 1IDnIhrp Engineer 2 T.,. Name(e JOSHUA PPPP DnllMs Compeny ARCADIA DRILLING INC. DrillerileneenRni ee Signme, Address PO BOX 1790 2874T --r' T Drillmm uairAe Llce:ee No. Chystere.zip SHELTON WA , 99594 6TRAINEe.Dnikfs Licelme No. BRANDON HICKS s Cmmsomt ARCADDI098K1 Duc 1T2B/07 Drillers Sis"hurc' Regisualion No. Emlegy ivM F4YM OppmmaY FmPmyer ECT a5P1�3afRw W» Thurston County Environmental Health 412 Lilly Rd NE Olympia, WA 98506 - - - -366867-2631 'tHUgS1UN COIIN'1'Y COLIFORM BACTERIA ANALYSIS Dab Sample Calbcmd Time Sa Cm mple mty `I 11D57 'ma5ar wt' her Yv Type of Water System lcneckmry onebox) 15Qoram HooseAam ❑Group A ❑Group B El Other Group A and Group B System Provide from Walter Finalities InventoryMR: - - Stamm Name: Corew Person: VaL U Day Phone:( D U Coll Ph 4 1 E-mail C. Ew.Ph.'( ) a:lPnnlall name,a ..d oodem all r S8 SAMPLE INFORMATION/� Sample mlbcmd by(name):, IO G U I C I V saG speciticm�pap^nto-r meamesamPb q SpacialinstrncUM&COMIMMS: �lTt1 �� YV/Y Type of sample(^rose chin k a*one box of p1 through#4 here below) 1.❑Routlne Dbtributlpn SmnPb 2.Repeal Sampb Itlbrumat routlro) Chlorinated.Yes_No_ ❑DWbution System Chlonne Residual.Total_Free_ Channeled-Yea_No_ 3.Raw Wabr9ouoaellample Chlorine Resduel:Total_Free_ ❑E.mG-GWR(NP) ❑Fecal-sue,cw.m rr m n) Unsadaleeary routine lab number. ❑Assessment Whohirg(Aml Unaatisfackoryrerinecollecldam: ❑Omer _I_l_ S Sample Collected for Inbmmtlon Only Inve*gve_ ConebuctionlRe he Other_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Ureabefscbry Total Colib-m Present end o itorm delecled ❑E.colipmerd ❑Etod abaerd Replacement Semple Repuhed: ❑Samplewold(>30houo) ❑TNTC ❑ Bacterial Denshy Results:Total Col'dorra It00ml. EMN I1DOMI Fecal Colib-m AD0o1 Enmromc8 110Dm1, Meted Code:[!�SM 9223B ❑SM9222D Otl eM Tma ❑SM 9215B ❑Enlerobrl& IZ'Lo''uP 0$GS MeeMTm Arvid ea: I'L' 10' yrf wee Reposed 2I . s.ewwmemlooxnreewpwrm4ptel tabUeeoxy: og31 0 6 0 �5 _ Cub a oox semevw-slmveeamnN /2.'lA_I . 2221384 MASON CO WA 02I06I2025 01 KAL .10 PM N6TCE IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII6306.50186 Paden 2 Retum To l n r1 n, Kee4ve6 ir��TTle-4 �'^^� "Tor, A /Errol 1u -Mi -zj Grantor(s): (1) �30LC! J6tL-f& %2L� Grantee(s): (1)PUBLIC n C ^y Legal Description(1) (Abbreviated torm:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1)A— Z 2�Z-i—1-_qL_QQLQL 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) Tax Parcel: (Connection The system owner is responsible for keeping this system in compliance. The name of the water system is: t\ .Gt,_ U' +f 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 day C Signature Grant s (1) (2) Page 1 of 2 State of Washington ) County of Mason ) I,the undersigned, a N,r9tary Publ' in and or the above rnnamed County and State, do hereby ce ify that on this ^`aa of�_. 20M personally appeared before me,who is known to be signer the above instrument, an acknowledged the he ) (they) signed t. GIVEN under my hand and official seal the day and a la t a ove w an. i ,,•DER SEY.,y N to blic' d fo a Stat of Washington, ,,, io•��, y re ing at OTARy 4^a: ,I'i My commission expires: j 23038426 's N:• PUBLIC . ':yam•.14!17�+.0;,d' OF WpSN`!V`J_ unuww Page 2 of 2 3VI J ,Stoft MweAlwy 3�4' q,�I;q- II- 90010 TAy(, I la- 14 .On scn4. i"= 100' i PISS WR-__ "Br\ i sul� I.�S y a 1 AP ROVED MC PUI JUC HEALTH O 6q CG DE 2 0 2007 �Sa. fit + JO Nu o1� 1170' uE �2"� ;r PR.� PUSED In =2o� y APPROVEDm . y � MC PUBI- IC Hm m COX m APR 0 6 2012 c m Y ADR z.a EXIST-. TRA-jJ S , LIhIF I ' �a ERTG EXPIRES 08-09-IY I