HomeMy WebLinkAboutWEL2025-00014 - WEL Application, Design, Letter - 5/7/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
elipti
BELFAIR:360-275-4467,EXT 400
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
WEL2025-00014
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, qA
A
�ON kik
David Anderson '1'7)- ?? k%40
Environmental Health Specialist �✓ip, �1s
Mason County Environmental Health 4 NTq`y
F9�rti
7--,,our nn,y,�.`, Z// / / VV ?$?` (�, MASON COUNTY Date Receroed: ZZ..++ II f
,l 1. `i COMMUNITY SERVICES Amount Received: ��.. Received By t
.:t Building,Planning,Environmental Health,Community Health
415 N.6'h Street,(Bldg 8)—Shelton,WA 98584 W E L Z r7s -'OV l /
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT V q ` 6 r— PHONE JC r— ^I „^— OJ9c
MAILING ADDRESS--STR[EET,CITY, 'A" ',LIP 1ellt � 6V' ,'( U v
26 ( /la Ali/fo n Rel IV
SITE ADDRESS
L O RE Clv tlf(STATE i7.IP el /nc/ Shel ffri kMA f5'5�`/
PRIMARY PARCEL NUMBER( ICI SITE)
l/ `J
52.02 y - -Saalo
SECONDARY PARCET,NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL)
Za 2 ` 15 -5004/0
W TE )URC. SOURCE'TYPE PARCEI.I LOT SIZE(min I acre) PARCEL 2 LOT SIZE(min I acre)
New "Existing �Wc11 Spring 6. 70 f ?‘
PROPOSED WATER SYSTE I NAM T:(REQUIRED).
11 f h c ` Lot-- 3 ' '
PROJF.0 ESCRIPTION(e.g.,detached Ant:,new single-family residence,existing connection.etc.)
DIRECTIONS TO SITE/CONDITIONS i 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
CS1 Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
41 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 County website. Revised:01//2025
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ izi ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
0 ❑ ❑ Are there roads within a 100-foot radius of the water source? 1 t
Is the road O ounty,or State?(circle one) Distance to the road(s) ~)0
❑ ❑ Does t'I ground slope away from the water source site?
P ❑ ❑ Satisfactory well cap?
lti ❑ ❑ Well cap screened and vented? Q►i
❑ The well casing extends (3 above level ground/concrete slab?(circle one)
(1'r le ❑ Evidence of a surface seal?
Lat: if 7.toe66
�g115 ❑ Adequate sur ta: face seal? Lon: -1 z;,j,.j j$7
❑ p ❑ Variance necessary for well site approval? Tag: 8'Pivarg
Comments: VolItof seedto ,fa /Pve/,
y ccIree cl )1o77O?,r t
Pass 74a Inspector Date S//l Zo? J
ji ti 1)s-- _
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water well report(well log)with a concurrent capacity test?
❑ ❑ pi Nonconcurrcnt/separate capacity teest/?/ / n
Capacity test information:Date v( I .7(10Z Driller �4,1 c2 Pt" L t C.
/� (minutes) Total Gal 'Q'v()
GPM VD Duration �� ll
❑ IDSatisfactory bacteriological analysis? Date of test 7(5//?0 G C(
JAI
❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z l % 0�
❑ ❑ The system appears adequate to serve two connections based on the information provided? /0�
o
Comments: Mqsa M,Q)'O �1)
-cooly ?0,s
-
cooly?)
"Approved ❑ Denied Reviewer Date 5kr/ 4fFN744 y
FQzT/
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 19h, 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
wiiiiimillr
•
WATER WELL REPORT Ot..'\47MEN: O. Notice of Intent No. WE55426
ECOLOGY Unique Ecology Well if)Tag No. BPN058
Type of Work: IS.,.,. .1 • ., I. -.,,.
Ii Construction Site\\'ell Name(if more than one well):
❑ Ikcummissiun i ' Original installation NUI No. Water Right Permit.Ccrtilicate No.
Proposed else: • Dmttcstic Industrial Municipal Property Ohncr Name DAHL PROPERTIES LLC
❑Dessatering —Irrigation =Ted Well _Other _
Well Street Address LOT 3 0 HIGHLAND RD
Construction Type: Method: MASON
25 New well _Aitetation ._ Driven L i ict d =('able fool City SHELTON County �-----
I !Deepening I Other Dug I Air- Mud-Rotors l ax Parcel No. 52024-13-00000
Dimensions: Diameter of lmittp, 6 in.,in 50 Il. Was a variance approved for this well.' Yes '❑No
Depth ufcnmpki tl well 50 11.
If yes,what was the variance for'' _--
Cnnstructinn Details: Nall
Casing Liner Diameter From Io Ihickrte... Steel PVC Welded thread
p 1 ❑ 6 in. +1.5 50 .25 in. LC 1 ❑ I ❑ Location(see instructions on page 2): 112\V\'M or 0 EWM
1.1 I t.I in. _ _ in. l I I I .I I ..I NE '/,-'/of the SW V.:Section 24 Township 20N Range 5
❑ I ❑ in. -- in. ❑ i J J 1 ]❑ 1 0 in. in. ❑ 1 0 DID D
Iaitudeliixamplc:47.123#51 47_20872
Longitude(Example:-12(1.123.15) -123.25272
Perforations: ❑Yes E No Type of perforator used _-
Driller's
No.of perforations Size oftxrfn:Mon. in.bs in.
Log/Construction or Decommission Procedure
Formation:Describe by color character.yin of material and structure.and the kind and
Perforated from 0.to Il.below ground surface caterer of the materiel in each layer penetrated.with at least one entry for each change of
Screens: • Yea I Nu •K-Packer b Depth 44 1. information. I:se additional sheets if necessary.
Mannfacturcr'.Nano JOHNSON Material From To
-lope STAINLESS Model No. 0 4
SANDY LOAM
Diameter_5 In. Skit svc 14 in.from 45 ft.to 50 ft. 4 25
Diameter inSlol sine in from 1i.to If BROWN CLAY GRAVEL
SAND BROWN 25 35
Saud/Filter pack: Yes 3 No Size ofpack material in GRAVEL SAND WB 35 50
Materials placed from_11.to_li
—
Surface Scat: Y. Yes ❑No To what dcplti! 19 I.
Material used in seal 3/8 BENTONITE CHIP --
Dad any strata contain unusable hater'! 0 Yes MI No
Type of water! I/e tut of:Amin ___..
Method of sealing strata till
—
Pump: Manufacturer's Name Type:
II.P. Pump intake depth:_It. Designed flow rare:_gpm
Water Levels: Lauul-our face Iles abou above wean sea level_11.
Stick-up of top dwell casing 1.5 If dove ground surface
Statue water kw! 16 tl.below lop of well easing Date 06/17/2024
Artesian pressure lbs.per square inch Date -----
Artesian water is controlled by (cap.sake.etc.!
Well Tests:
Was a pumping test pet formed:' a)No :l Yes c= by whom?
Yield pmt with_it.drawdown alter has. —
Yicld _pm with_IL dmwdow n alter his. - —
't iced tpmt with IL drtwdown after hn.
Itecoser)data(time-ecru when pump is turned all-water level measured from well
top to hater level)
Time Water Level Time Water true) Tine Water Lose)
Dale of pumping test ___-
Bailer test gun with_II.dims doss a after_tin.
Air lest 100 ppm h itlt stein set al 40 II.fin 1 hr.. Date D6/17/2024
Artesian flow min
Temperature of water I' Was a chemical analysis nude'! C Yes ®Net Start Date 06/17/2024 Completed Date 06/17/2024
WELL CONSTRUCTION CERTIFICATION: [constructed and or accept responsibility for construction of this well,and its compliance with all Washington well
construction standards.Materials used and the information reported above are true to toy hest knowledge and belief.
E Driller❑ mince❑ E—Print Nance ROBERT LAYMON Drilling Company ADVANCED DRILLING LLC
Signature y� Address 11530 SCHOOL LAND RD SW
License No.2588 City,State.Zip ROCHESTER WA
11:TRAINEE:Sponsor's I.iecnse No. Contractor's
Sponsor's Signature Registration No.ADVANDL804DL Dale 06/17/2024
ECM'05(1-1-20(Rev OS.19)11 rout need this document in an alternate torus.please rod!tin:Water Re'WItret'S!h•u4rant ill 360-4(/'-687?.
/'rescues with!hearing lace can roll 7///nr tl tve/l/gttnn Velar Set eh e. Persons with a..perch di.abuIilt'ion<all,Y'--.\(3-b./J/.
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2221776 MASON CO WA
Return To 02/18/2025 03 11 PM NOTCE
DAHL PROPERTIES`} 11LLL�LC 42 553 Rec� Fee $304 50 Pages. 2
Dahl Properties, LLC 11Imlll111111111 111111111111ff 111111 111111111IIIIV
261 N Hamilton RD .'.k
Chehalis, WA 98532
0 +-ifr <`4\
�0 FG 6'�D�
F� s
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 0 4 _ t 1, , 3 _ 5 0 0 3 0
SQ(t'1bY-) 2__ •W iv 2r, nQ. C
NOTICE TO FUTURE PR* 1FWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersig r t(t`, certify that the water source located on the above-described
real estate under gal Des�cription (1) and Assessors Tax Parcel (1) situated in Mason
County, State of hingtdt�, has been designated to serve a source of water to the following
parcels situa ounty, State of Washington; herein described:
Tax Parcel. C ec. 1) 5 2 0 2 4 _ 1 3 _ 5 0 0 3 0
Tax P I: 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.
( the
water system is: Highland Lot 3 & 4
s 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
em 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+4' d Ft1 1,140:. , 20.2_
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 tnty and State, do hereby
certify that on this I7 day of F.ebYtAAY , 20
Ca vi Dah1 personally app ed 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 ove written.
EITER
Pi)A-- c-
RESNO7AAR YPUBUSC
�1ot lic in and for the State of Washington,
STATE OF WASHINGTON License Number 167937 rest gat /ZIA Wilk
s
COLA U vl k
My Commisston Evires 14,2027 M mmission expires: 1- .07]
1
0
Page 2 of 2
2221776 Page 2 of 2 02/18/2025 03:11:13 PM Mason County, WA
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