HomeMy WebLinkAboutWEL2025-00014 - WEL Application, Design, Letter - 5/11/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
J` SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467, EXT 400
f Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
DAHL PROPERTIES LLC
261 HAMILTON RD N
CHEHALIS, WA 98532
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2025-00014
1507 W Highland Rd
520241350030
The 2-party water system, Highland Lot 3 &4 (520241350030/520241350040), 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, CO 0
David Anderson /kiy �� ��
Health
40,
MasoEnviron nmental County Environmental/Health st 04/4
;A,F �s
�Tti
filet ........—
•,.1.
� ' MASON COUNTY Date Received: Z.// 7/?
)( y
,l 6 COMMUNITY SERVICES Amount Received: Received By. 1(7 / /
Building,Planning.Environmental Health,Community Health
sad / e-
/ 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 W E L 7 �>/
t/
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 Z _���/ {
TWO—PARTY PRIVATE WATER SYSTEM APPLICATION
APPAPPLICANT "(/n+ \ PIIOYF, 16"0— `� - O
MAILING ADDRESS CIT\',STA 71P eS C. 6 r 66 U Sys`
a 2 ( ia'n//toe) (Zd Iv
SSITEA �t STREET,CITI�STA7't,
I 1 0c/ c/ s4 e f/Gi tv A 7-8'5 /
PRIMARY PARCEL NUMBER( lei,. //SITE) t/
SECONDARY PARCEL NI (SAME�O�I; PRIMARY IF LOCATED ON SAME PARCEL)
ZO z ct - 15 -5Oo/O
W.TE OURC'. SOURCE TYPE PARCEI.I LOT SIZE(min I acre) PARCEL 2 LOT SIZE(min I acre)
y
New 'Existing Well Spring 6, yU S ?C
PROPOSED WATER SYSTF NAME(REIRED).I L
1i h/�tc(ivi
LOT" j ///
PROJEC FSCRIP[ION(e.g..detached Am:,ness single-family residence,misting connection,etc.)
DIRECTIONS TO SITE./CONDITIONS/GATE CODE/KEY LOCATION/ETC.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,water lines,property easements,etc.)
Required Submittals Checklist: (additional information located on the first page of this packet)
Satisfactory bacteriological test from within the last year
Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day
rag Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
`t' Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and made available for public viewing on the Mason Count)'website. Revised:01//2025
Page 1 of2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ gi ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
[� ❑ ❑ Are there roads within a 100-foot radius of the water source? t
/` Is the road ounty,or State?(circle one) Distance to the road(s) ~)0
AI ❑ ❑ Does t ground slope away from the water source site?
cr El ElSatisfactory well cap?
r ❑ ❑ Well cap screened and vented? .i
ElThe well casing extends 'f{ above level ground/concrete slab?(circle one)
.(i '$611) ❑ Evidence of a surface seal? Lat: to.toad
srg45 ❑ Adequate surface seal? Lon: -1 Z;.ZJ j gi
❑ N ❑ Variance necessary for well site approval? Tag: 8 P✓Drg
Comments: I L Of lCd �f� /eves.
7 C fr �'a�/7a?f
0" Pass 74717 Inspector Date 5///ZQ 5-
sti k-- _
Review Step 2: Two-Party Review:
YES NO NA
Ai ❑ ❑ Water well report(well log)with a concurrent capacity test?
❑ ❑ X Nonconcurrent/separate capacity test?Capacity test information:Date 0.7(/ Oi lOi t Driller / 4 agall M LGG
GPM /00 Duration(minutes) 60 Total Gal gv
❑ ❑ Satisfactory bacteriological analysis? Date of test -7(5//70 G C(
❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z Z.Z ` % �
❑ CI The system appears adequate to serve two connections based on the information provided? pp
o
Comments: Mqs6 Mq y 0 �1)
NcoUN "20?s
_ nF1N
Approved ❑ Denied Reviewer Date ,$ v! L �l�`" ReNT9(H
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,express
or implied of the future success or failure of this system. Well site approval does not constitute water system approval
All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19'h, 2018 per ESSB 6091.
Revised:02/04/2025
This form may be scanned and made available for public viewing on the Mason County website.
Page 2 of 2
WATER WELL REPORT Notice ollntcnt No. WE55426
ECOLOGY Unique Ecology Well ID Tau No. BPN058
type of Work: r;•
El Construction Site Well Name(if more than one well):
0 Decommission Original installation NUI N . Water Right Pcnnit.Ccrtilicate No.
Proposed else: • Domestic estic Industrial Municipal Property Owner Name DAHL PROPERTIES LLC
Dewateriug -Irrigation -Teat Well _Other
Well Street Addre.s LOT 3 0 HIGHLAND RD
Construction Ts pe: Method:
E New,Dell .\ltcrnion :=Insert C kited Cattle Iool City SHELTON County MASON
Deepening I Other Dug I■ Air- Mud-Koury -far Parcel No. 52024-13-00000
Dimensions: Dianetei of(snit% 6 in..to S0 II. ONO
Was a variance approved for this well.' Yes
Ucpllt wl'eompktctl local 50 It.
If yes.what was the variance for?
Construction Details: Wall -----_-- --- - - - _ - -- --"
Casing Liner Diameter limn to thickness Steel PVC Welded thread
alp 8 in. +1.5 50 .25 in. rJ■ E 5) ] ■
I I Location(see instructions on page 2): �11'\\'fit or U F.W\t
Ll I i-1 in. in, L.I I I I I I NE y,_y,of the SW y.;Section 24 Township 20N Range 5
❑ I ❑ in. in. O I D J 1 D
Latitude(Example:47.122345) 47,20872
❑ I � in. in. O � 7 � � �
Longitude(Example:-120.12345) -123.25272
Perforations: 2 Yes ]No type ul'perfolanor used -� —
No.ofperforations Sue ofperforation:._in.by in.No. Lag/Construction or Decommission Procedure
Perforated from tl.to 11.helms ground surf Ce fonna err mon:Describe by color character.?ITC of nutat and structure.and the kind and
nature of the material in tacit layer pent:rated.with al least one entry lot each change of
Screens: • Yes i No •'t-Packer Depth 44 9 information. t'sc•additional ht vts ifnecessar•.
.Ia:ndaelurer's Name JOHNSON -----._ Material From To
type STAINLESS Model No.
Diameter 5 in. Slot svc 14 in.from 45 n_to 50 li. SANDY LOAM 0 4
Diameter at Slot toe in from_u.to 0. BROWN CLAY GRAVEL 4 25
SAND BROWN 25 35
Sand/Filler pack:-Yes No Size ofpack material in GRAVEL SAND WB 35 50
Materials placed from IL W Il.
Surface Seal: i Yes O No To what depth" 19 lt.
\la:crial used in seal 3/8 BENTONITE CHIP
Did any strata contain unusable water:' El Yes L9 No
tyre of water? I)elth of strata
Method of sealing strata oil
Pinup: M:muktcturcr's Name Type:
I I.P._ Pump intake depth:_It. Designed(tow rate: grin
Water Levels: Laud-sun face elesatiun above mean sea level R.
Stick-up of lop of well casing 1.5 Il.above ground surface
Stalk water ksel 16 Il lelory tap of well easing Date 06/17/2024
Artesian pressure Ibs.per s.pivr inch Dale
Artesian water is controlled by (cap.sake.ctc.)
Well Tests:
Was a purr:ping test pet firmed" !7 No 71 Yes l by whom''
Yield frin with_IL drueduss n alter_hn. —
Yield gnu with tl.dnnvdaw n after hrs.
Yield grins with Ii.dmwdown tiller hos
Recovery data pine-nro when pump is turned off-water level measured from well
top to water level)
Time Water Level I'intc Water Level Time Water Lescl
Date of pumping - ---
Railer test Hurt will,_li.dins dust n tiller_hrs.1 -_
Air lest 100 ppm is ilh stem set at 49 11.Iim 1 hr.. - Date 05/17/2024
Artesian flow 67tm
Temperature of seater .I. Was a chemical analysis nude". C Yes I!Na Start Date 06/17/2024 Completed Date 06/17/2024
WEI,L CONSTRUCTION CERTIFICATION: I constructed and or accept responsibility fur construction of this well.and its compliance with all Washington well
construction standards.Materials used and the intbm)ation reported above:use true to my best knowledge and belief,
O Driller O aince 0 E-Print Name ROBERT LAYMON Drilling Company ADVANCED DRILLING LLC
Signature Address 11530 SCHOOL LAND RD SW
License No. 2588 City.State.Zip ROCHESTER WA
IF-TRAINEE::Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ADVANDL804DL Dale 06/17/2024
ECY 05(1-1-20(Rev(IS+I'))if tutu urrd rl(is document in an alternow format,please ran flu 11'atrr Rtsuun•cs PruRrum u!360-407 OS72.
Persons with hearing Inca can call 711 tin 11 ashisi•>;lnn Relay Sen•icc. l'erl•ons with u peel'/)di cabilill'C an(all uf''-A t,(-h34I.
- _ �-
.•. L-i**- inc,c-J
C _ a )
..ip•
_ , .-cir
CD
s. ECD ... Q)
r " j_ E l iy +
i picn
n c
f) o -0 .. 0
\l "--- cr) Ns..4;')Ns..."\
mliE ti
r N
4
.... _. ,.,.„
. w T
W,
m a2 cc, . ......_ ,
c.
s mm Y O
S U O C
N N E vi
a@ p id cvg J
I E LI- c
Z
.'sg . 5 .
c, m E o
1O v a E
as
co
CD
to• O U 7 C O �— O ❑
yy yy�� Zo
0 co
0
cc so.
ay i— m n- ,O O C N d N is w l "
`. P. .. m O. eJ
i Qce
is O 'o
ALL.,, d O A 13 E �. ® ��! .C.) _O C a, 6 O
"t�lw c c o m °) cc _ E 512 W. CM o ro m o N
Yea C4 Sc o - Q = 3 tti . ❑ R U CD R E Q ~ m
.4 .
4 I , yy�i ❑ U U c9 ❑ ❑ W w 4 8 �a n ❑ til t� o x
m •kg. '- c�i v ❑ 7. .. ❑ m o r•. c o of o
yin
• t�
,3`a :,r, m
. ram? h-- w. ;fir; E
'9y 'Q C � 'tt '� O
co
i 'I = c
.R .,v1Ql. a cl- la '� p j--- C
_ A &. i
❑ sz
�,$ s -
'� p i O m ,(1 f u ice; Q •
Q.
Fa eo' c%3 Fa —5 C•ig --.‘ _e
•r': T
^fr! 0, U _ coa C7 i d ro — -0
im` � C1 - s O "O ' m p� tOi`7 �1 g a ..; .. NP 4 .
a�! U ) J
Mr1IDId !
Q`\ 7.
Send results to:(Print full name,address and zip code)
YZOJLctv0ec
•lie .13
r )v f
I y i
t+J 43 E
la 1
2221776 MASON CO WA
Return To 02/18/2025 03.11 PM NOTCE
DRHL PROPERTIES LLC 42 553 Rec Fee $304 50 Pages 2
Dahl Properties, LLC HMI I IIIII11II I1111111II1?lllllll1 IIIII0IiIIIII!!IIIIIIII VI
261 N Hamilton RD
Chehalis, WA 98532 O
ci,-•0 6'
Grantor(s): (1) Dahl Properties, LLC (2)
Grantee(s): (1) PUBLIC
Legal Description (1) LOT 3 OF LLS #23-03 AF 2205952 SW NE S 54/70
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 5 ��2 0 4 _ 1 3 - 5 0 0 3 0
NOTICE TO FUTURE PRC'''�'' WNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersig Ni.' ( , certify that the water source located on the above-described
real estate under gal D cr' tion (1) and Assessors Tax Parcel (1) situated in Mason
County, State of hingt , has been designated to serve a source of water to the following
parcels situa County, State of Washington; herein described:
Tax Parc • C r)necton 1) 5 2 0 2 4 _ 1 3 _ 5 0 0 3 0
Tax P el: nnection 2) 5 2 0 2 4 1 3 5 0 0 4 0
Th s own r is responsible for keeping this system in compliance.
çthewater system is: Highland Lot 3 & 4
sy• em is designed to provide for two service connections. Planning and design approvals
_: obtained from the department prior to expanding beyond this number of services.
d•itionally, a water right, obtained from the Department of Ecology, is required if the water
`''tern exceeds exemption standards.
This system (has/ has not) been granted one or more waivers from specific provisions of the
regulations.
Dated on this 1'7 d FtbryaV:91 , 2025 .
Signatur of rantor(s):
(1) , (2)
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above na ty and State, do hereby
certify that on this 1/4' day of F3e0YUAV's , 20
COIN QAh\ personally app:.,�+ fore me,who is known to be
signer of the above instrument, and acknowledged tha ;- e) (they) signed it.
GIVEN under my hand and official seal the day an - • move written.
OM
REBECCA R. MElSTER `,wo';� �� =
NOTARY PUBLiC 'ota•1`tiblic in and for the State of Washington,
L
TE OF WASHINGTONvetense Number 187937 resfi rig at LkAl\A Cummission Expires April 14,2027 M commission expires: 1� 2D2 7
D
0
Page 2 of 2
2221776 Page 2 of 2 02/18/2025 03:11:13 PM Mason County, WA
' - � Q , \
/ ��111/W 1 r'/ \\ \\\\\ik\\i
\\\. \\\ \ \ .�I
/ � \\\\\\\\ \\
1
/ '
1
5
I o
ii
g Z 01
L.
`, y/cy
C9��'lb '1
L-1- - 4 T - , �S
m
v
c, �, 1
> o C 1 ! i
No m _, o vi 4v
> R° O m Om cm� /
€ T g m g , 'g JGnC�C;iC>!:>!�'
o i , g
i A
y Ti i I
z a
? *1 i r n
s I 14
9
A
— ` —..— —�n— 1------__ ,
II Il •
Y
i
{` 4•
U• 4
II --
r
Can 4 �)
w`•Cam~ s�.
Nv 1
may) Ws.
.: •
§ i
ti
'�' �• `
rat 1 I 1 a 1111� 111 1 Pi * W
ili
i 3 a 3jx -- - -
i2. 1 1°111
1 I irlii
\ i i lipa • * ; IMO
1 ! 1110I q i IP
iii;iIT11I 4 L.i' i
,� i