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Home My WebLink AboutWAIVER FOR WEC2003-00119 - WAI Health Waiver - 7/15/2003 • MASON COUNTY . li DEPARTMENT OF HEALTH SERVICES -- mlin,,f,r, ii I i Environmental Health Water Quality 'erso , Health LOCAL(360)427-9670 Application for Waiver/Appeal BELFAIR(360)275-4467&4468 pp TOLL FREE 1-800-562-5628 // r FAX(360)427-7798 Amount Paid: /UU Receipt Number: /4 3 /S /1 Instructions b 1/ ........„, ,;.; .;;::>::. .: <� �• �.:: <�t'.<1ull. tom leted > �><<<l <>>:`<'> �s :,.:::::f.,:<.,:v. ete.. . ;• ;: lt1d: .:,:t?I�. �ec .u�.at�Rgaitttliii#1"1:::?:.>:;:.:;;:>:-;;:.;::.::.: `::.:::::::p'::.�::::::::: '{v:?ii4::i .i}:ii::�i:':•::::.�:..�:::.� ...i'i' .y..pv.}4•:f4y.;'.;....::w::�:::::::;.:....::.,..:v•:..^�.�$'�. \ }'ri :;:<., �. . , a <�be tllod>#'or:>. Vet ::auR :......s= s.. .. f VuOtt�ielflail healt fee sehedul. ::>::>: »::>::<::»>>:::> ` ;: .. >:>::��<::l eta lit.. xa imiii:atlachments>t1o: "'':�t [th opt mane:t`odiiiii:>::::;:::>:> ::>:i;v:< !iiii::::»::>:::::>::>:: .;:;r>n::�;>...Subrn:tt:�oa�ple� I?tt � PART 1: Applicant/Parcel jcientification Name of Applicant �14 :Li_k tc.Q- a Date Tti !S, �U o 3 Mailing Address no T, ,..., AI _LS Telephone 360 -8,$- (o W ( lX z ,.. LkA Iii55 .L Assessor's Parcel Number 3 2a 3 S 7 d 3 a I "e.,�'4WJo2 D, Subdivision Name and Lot T 1 VV A•¢v l A e,S S 4 c) Q , .) o'^ PART 2: Nature of Waiver/Appeal ❑ On-Site Sewage Requirements 0 Food Sanitation Requirements ❑ Building permit review policies 0 Solid Waste Requirements a Location, WAC 246-272-09501 0 Group B Wat t,I? •ri i e tsT g, c) o Holding tank WAC 246-272-12501 ONWater Adequ �° �11� 0 On-Site Standards 0 Enforcement ' e ines ❑ Certification contractor(pumper, 0 Departmental.Determina , 1 Z 2003 designer, installer, O&M spec)requirements 0 Other Description of Waiver/Appeal(include justification,additional ater'al may be a ched): . C A LTH EBV ICES Nam LV�I\ 1� �.-A. 5,,,-t- . S Acoc a-c4-0 ,..05 , s rX 1, L) 4 4 c.Le S,,r- S,.1 e iv- i-.. 4- , DOE S 4-e,,A-C(•r d • 44- w E 0 L a z 0cal ..,:kQk z'...l 2 ,afz ., w .103, S . C ,�c,„.� � �-- J�48 At gr►4( let{ar ccro� Arslt . ate&: Or; re . 1,‘(Ls of i4-.S.. S, -t Applicant Signature: iti j ,1 Ft,r o)c,t.t v_vi Date: 1 H:%WDATAWRCHM:.!Y41VER WP Update:April 25,I S PART 3: Health Department Evaluation (Staff Use Only) IA. Type of Determination Required: 1 B. Type of On-Site Waiver(if applicable): ❑ Appeal 0 Waiver 0 None required 0 Class A 0 Class B 0 Class C 2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest code/standardl revis-ion)-:, W ztln a-rt a U[9-cy 3. Nature of Appeal: U P4-? i , ,(J,Ny .�cw,,Y,. f fi�eu. t 1' 7 aLt i l(Fa. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control Hearing Board 0 Health Services Director ❑ Certified Contractor Review Board 0 Environmental Health Manager 5 Mitigating Factors: I)LA '- 2.co3- 0U(ty J) Dol✓ wCo1Z4z_- 3) L(-4-t4-. itt,e.--!,1 6,-l-e-E/ •= -te, L) Local w-ceo I,yp. u � I/� L , C....-a./ 4; - .-÷4--%J saw- btJJ h d..' ban au.E -41 6. 1 have reviewed this waiver/variance request. It is complete, and mitigation required by state and local policy has been submitted. Staff: (:- (��Ct-ki'o Date: F( l C/ts3 PART 4: Determination of the Hearing Official The hearing official has determined that approval of this request will not adversely affect public health and is h rcby granted. tThis decision is based on the following findings and conditions: 0 The hearing official has determined that approval of this request could potentially :\..e l c\ This decision is based on the foil wing tt d t public health and is hereby denied. U � w.-- '‘ --aie: C73 Hearing ' 1I:1WD4TAWR' 'LIW4IVERWP Update:April 2 .>>7 MASON COUNTYti OF HEALTH SERVICES .- iiii ai .I I 1 DEPARTMENT !I,e ;,�., Environmental Health Water Quality 'erso • ealth PO BOX 1666 SHELTON, WA 98584 LOCAL(360)427-9670 Application for Waiver/Appeal BELFAIR(360)275-4467&4468 TOLL FREE 1-800-562-5628 ////`` FAX(360)427-7798 Amount Paid: /ZO G' / Receipt Number:J f4c /d `7 1 Instructions1/ 5 ......... ::... ,:::::::::::::..:::<..:;:::;<.:�};:<:>'.::.::}:.::::»:<::.:::»::{:»:»:<::»:::>: .......:.::.:::::::.:..::.::::::.:,::.�:.:{•>:.}}':{.}}:•.}>:: .,•n':<::}:.>::{.}..}:{.::�>;�.}:>.>:y:::._;::::.::::. .:.:....... .{ :: il.<::ccsm feted.:.:; > :::::':»:: ;.>:;:<;{<.: :; :>:::;:..,:{<;,,..:.,m::.'::.e •........ . .}.d 2. ...: : ;' ade::uinttl:these pa its are fu•.:Y:co::p:e:::::,:,.:.: >:. ;:.:;. , , . { rim...... .:.........:..:.........:.. ..........:..... ;.}>:::.;>:<{.}}:.>:.};:.:;:.;:}:}::.}:.}}:.}}}':.;::>::>.::.<::�>:>::::.;:;:«>::>:::<:,>::»>;}:;::> ,.>:<.<>`�:..}.� tetet�P�?cts:I.}�c�.� :::v::c • .:::::,:.x.::::.:;.:�i. : ::: .}:�:::::::::::.};}::.:::.:..,:.:.};:.:::::::.::. :::.}..:. .:: .::::.,:. . ..�:.:;'::t}}:,xfi:..:clap}:.}:.}:>:.:,::�:. .,..,...nb ...:.,. .....:.��. .fir.. . :6C&�t1S :.,. .... ... :. ... ,..,,..........:...:.. .................:...:::::::::::::>::::.::::::::. .......:::::::::>.:<:.... :::.. ..... :}...:'in'� :•::r.r..f{�•}:{T.},\y�...{.�tr•Ur'•.>:�. ....: ?Y.�.v}]P'fZ. .'Yvvk•�. .;.}. ..... ...... .. �: ;: ::- yf(./'�::.i;..:.::i'v:vi}ii'rii:v:y:�M1:::i.'•::�:::Ti+:::�: .N.`;^Y{.vv:::.A :}v: ...::.:?T:•4•Y• .{. v0' ti y. ��< �v� iic�i�ri��iii�ip��t�d�pp�tca>s;,�xiT�:ati�ciucti.�nt�:tu>�e�:health:.dapa�meut. ex�e.� PART 1: Applicant/Parceljdent�cation ?„10; cam- Date v �, l5, �O 03 Name of Applicant Mailing Address n 0 T. w. j-. . L,L.S Telephone 3 6 Qi -8/8' Assessor's Parcel Number 3 2D-. JS 7 S q b3 a I .'"e_.--e- 9o32 Subdivision Name and Lot T t '^^ �.54vTt S Q ,,13-,nr PART 2: Nature of Waiver/Appeal Cl On-Site Sewage Requirements 0 Food Sanitation Requirements ❑ Building permit review policies ❑ Solid Waste Requirements ❑ Location, WAC 246-272-09501 0 Group B Wat t .n. it \ % Di o Holding tank WAC 246-272-12501 ,N Water Adequ e :., t Standards 0 Enforcement ' tines o On-Siteer A'c, 12 2003 ❑ Certification contractor(pumper, 0 Departmental Detetmina , designer, installer, O&M spec)requirements 0 Other is 1�� Description of Waiver/Appeal(include justification,additional ater'tal may be a ched): i...4 A LT+I EE S c-tom 41,L--4,r t1 o 5 , c Ho i - wmil\ to et 4 I 1,...) Qr—AA. t44 c.1e S r.k c, Ste.,{ e R,- w.,, 4- l 006 s Q-w•�--c,-, -it E o I, (3‘ 2 tic al ,Te ,..l. 00 S . r„J 1. tik-f=. ...4-- l.e H� r o�. r A a,. a�b: ; I n... 1%co i s sib I a 4 L S �F,.,.1- 6,r Ko �u_ 4 —cr 1 Date: 'S O Applicant Signature: uree:: /'fr +� HAWDATAWRC1111':7,WAIVER-WP Update:April25.t`":7 PART 3: Health Department Evaluation (Staff Use Only) IA. Type of Determination Required: l B. Type of On-Site Waiver(if applicable): 0 Appeal 0 Waiver 0 None required 0 Class A 0 Class B 0 Class C 2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest code/standard revision): 3. Nature, � of Appeal: /�.4?-c--e,,,•/ 6 -a(1,N y -fie 4-4,,, f riu eu. h (.0-ai b ,"xi aL t.,v I J el, 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control Hearing Board 0 Health Services Director ❑ Certified Contractor Review Board 0 Environmental Health Manager 5 Mitigating Factors: I CA,EC- 7 0U3- ov(i9 d) uo e t' Oil z__ 4 3) L t.(.- i u,,,�, w,Ce/ aC= , 40 Lvcai w,<J2' tti L . /tYA t y �rJ ry a c C.c. c.y LEA %"-1-Q.� 4. S a-- b6 Ja I elt4 &esi ,r l 6. I have reviewed this waiver/variance request. It is complete, and mitigation required by state and local policy has been submitted.Staff: 6---41,./ a,,,,,, Date: r( (J '63 PART 4: Determination of the Hearing Official The hearing official has determined that approval of this request will not adversely affect public health and is h rebygranted. This decision is based on the following findings and conditions: 1 l `, kc-11 y'� . \i'f, 0 The hearing official has determined that approval of this request could potentially a I 'it pub lic health and is hereby denied. This decision is based on the foil 'tying LLO : . S 0 date:, ; -- U 3 , Hearing Vi- ' K:tWDATAVR( 11WA!VERWP Update:April ;7 File Original and Firs.COPY with WATER WELL REPORT :Start Card No. 082535 Department of Ecology Second Copy-owners Copy STATE OF WASHINGTON Third Copy-Duller',Copy Water Rent Permit !i~o. nC i (1) OWNER: Nome Don C. Warren Adam._ E 9051 Hwy 1106 Bninn WA 98592 ,- (2) LOCATION OF WELL: County Mason . SW I: SW v x S.c 35 T. 22 N..A 3W w M. (2a) -STREET ADDDRESS OF WELL(or nearest address) (3) PROPOSED USE: I7CDestic Industrial ; ' Municipal 0 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION Gotn Irrigation Deviator Teat Well 0 Other 0 Formation: Dsseribe by color. character. sue of motorist and stnlatwe. and show tMCkaesa of aquifers and the kind and nature of the motorist in each stratum penetrated. (4) TYPE OF WORK: D" «n .s Iwwba eu want Si least we wary for each change of inlorntatron. qt more thfn one)aw MAMMAL I FROM I To Abandoned I.I New well 21 Method: Dug 0 Bored C) — - -- j Deepened , 1 Cable ri Driven ri -- Reconditioned • : Rotary [ I Jetted 17 Brown conglomerate _._-- _.__-..-4 LZQ-. (5) DIMENSIONS: Diameter of well_ 6 inches. 20 i�— Drilled 58 feet. Depth of completed well 58 ft. Sand & gravel with water —F— (6) CONSTRUCTION DETAILS: • halo r13 n. _ - - -.— r---- Casing Installed: —_�].__• Diem.horn—0- ___--- --• _ J--Liner in Jd • Diem.from ft.to_ n' -- I —. ._.. Liner invaded I. ft.to ft. I` f Threaded I., ff• Diem.from Perforations: Yes CI No[ ..... ---- - t Type of perforator used -. i SIZE of perforations in.by m I . --- Oerforetions from— ft.to h - I - p.rtor.hoes from_ ft to n• • - - p.Aor.tions from ft to ft. II i ❑ I Screens: veil® No Manutach lfsf S Nams Cook - - - -----Type stainless --- Modatuo. i i Dlam. Ste slot size 40 lrom 53 n.to� -n I- ------ - - -- Diem. Stet sire from n.to h• I- Gravel packed: Yap Noti$1Le of gravel ' ! Gravel placed from ft to N. t de h wapth? 18 n - I Surfaceseel: Yes® Non To -- I Material used in soft BetonitP --�-- . ..T Old any strata contain unusable water? YaslJ NOD _ - ---4--- .. 4 . Typo of water? Depth of atrete - Method of sealing strata off -- -_ _.._ (7) PUMP: Manufacturer's Name Grundfos .. -. L. i Type,__ sub- H.P •--- - _ [ ,_ _— (8) WATER LEVELrS. "rid-.urf.eeeev.hon ft __ --_----- sbow mean sa lev.l. I Siamlevel 13 h.below top of wet Dais— - --- • Artesian pressure Ibs per agora inch DII.- - —---. -- Artesian water m controlled by (Cep.. .ate 9 ---- -- Work ne ��stad— 3lA—.-.19. Completed_ -.19-- (9) WELL TESTS: Drawdown is ataAle water lave.is lowered below static level Wes a pump teal maw?YeLI No LX It ye..by wheat? WELL CONSTRUCTOR CERTIFICATION: v old — gel rtwdt•vrdh _h drawdownaner his. I constructed and/or accept responsibility for construction of this well. and its compliance with all Washington welt construction standards. _— __..—_ • -- - - .- Materials used and the information reported above are true to my best • - knowledge and belief Recovery date(time taken ae zero when pump turned on)(water wives measured hem well Weal water Neel) Dri11in 'Nile'Nile Waistei level Tine WON Loral 7n Wiest level NAME Davis -- (PERSON.FIRM.OR C ATIOM) (TYPE OR PONT) _ • - - -- - -- — Address— Belfair WA 98528 Date of tea(_. (Signed) License No. 0797 _- . .... ( 4.(.... ER) Baiter test ._15L—pal r mtn.wd i-L---tl drew/down attar tiro• COntraCtO [�t Autsst -- paLinhn.nr,Mll�ttmatat. loafer his Reg12Pk M. isDI11ooA Oats Nov. .193i. NO.j�V 1� Artesian how ._ •_-ipm Date Tentpeatue of water--_ Waa a chemicalnety.is made? Yea Li Nos (USE ADDITIONAL SHEETS IF NECESSARY) 420 . File Original and First Copy with Department of Ecology WATER WELL REPORT Application No Second Copy-Owner's Copy Permit No Third Copy-Driller's Copy STATE OF WASffiNOTON _ - - John W W. Coker ._............. Address...... ...... ... . ... . . ... . (1) OWNEB: Name ............._...... ' (2) LOCATION OF WELL: countyMartQn - See ' Bearing and distance from section or subdivision corner - — (3) PROPOSED USE: Domestic ; Industrial p Municipal El (10) WELL LOG: - - Irrigation 0 Test Well 0 Other 0 ,and sFormation:how thicknessscribe by of aqutfersfand the kind and size nature of thel rd m tterialtineeach stratum penetrated. with at least one entry for each change of formation. ( ) (If 4 TYPE OF WORK' Owner's numberth oone)f.well ` MATSRI/1h FROM TO mo an ... ... .. . New well Method: Dug ❑ Bored 0 - - - - Deepened p Cable Driven 0 Reconditioned ❑ Rotary❑ Jetted ❑ —Gravel & clay 0--7 dn 7 ' 38 67— (5) DIMENSrI(ANS: Diameter of well ......_.6.... ... inches. Sand & clay ---------- -- 67 ~ 82 Drilled ..15P. .. ft. Depth of completed well.. 15P............_.ft. Hari n_ -- --_----— �Z 138 Sand, gavel & clay -_— -__- (6) CONSTRUCTION DETAILS: Cemented gravel —_— —1 '8`i51 Casing installed: 6. " Diem. from ... 0 ft. to 156 ft• Gravel & water 15i 156' Threaded 0 " Dlam. from .. ft. to ft• -. . . Welded Diem. from .. !t. to ................ n. Perforations: yes 0 No i 1l -_ Type of perforator used - - T SIZE of perforations in. by .. .. . in. j�� _ � --- perforations from .. . ft. to CO ... ft. to ._ ft. _ ,,,.,,, Perforations from ... /1 p� _ perforations from .•- ft. to n. g'1r 7 I__ Screens: yes 0 NO_I� e,Det,icrtmom of�+vyl Manufacturer's Nam .-..._..._......... ........_.._........._.............._----- aef O.,' t:CO�J�f� --- Type Model No.........__.............._.... 'tC0 ... Slot size ..._......... from .. .... . ft. to .... ....._.. ft. Diem. ........... ---- D(am. Slot size from .. .......... ft to ft. - -- Gravel packed: yes❑ NO Size of gravel:....-.. ... _.—— -_.-_ - -- — n.to... ft. _ ----— Grevel placed from ....-. - - • �- Surface seal: Yes j NoBen❑ To what depth? Material used in seal.. �toni to ---- - -- — - - - - - Did any strata contain unusable water? Yes 0 No4/ _ -- -- --_---- --_. ------ ......... Depth oftata strata.. - - Type of water? Method of sealing strata off.. . •-I- (7) PUMP: Manufacturer's Nana .•--•- (8) WATER LEVELS: Land-surface elevation — above mean sea level.... .../ -� - Static level 13 it. below top of well Date 2f i,f ••• ---------- Artesian pressure .. Ibe. per square Inch Date. ....... _ - -- Artesian water is controlled by (cap,valve. etc.) - (9) WELL TESTS: Drawdown Is amount water level is - - -' - - -- �11-II work started-...-..A l..2 ......--•- 19 Completed.. 2T• Ia lowered below static level Was a pump test made? Yes ❑ No If yes, by whom? J ft. draw after hrs. WELL DRILLER'S STATEMENT: yield; __gat./min. with and this report is •• This well was drilled under my jurisdiction .. true to the best of my knowledge and belief. turned off) (water level & Drilling {iO s Recovery data (time taken as zero when pump ,7 measured from well top to water level) NAME...Bede.11...FUMP Tone Water Level I Time Water Level I Time Water Level (Person. firm. or corporation) (Type or print) 1583 E. Dickinson St. Shelton, Wash. • i Addigth,„ lSigned].... )27:"'Ar - Date of test .... . ' " (We 1 Driller) /� fly 1.. hrs. Bailer test.. 3Q.gatJmtn. with.. ...t<. drawdown after 2/2/O1i al. Date. err Artesian tt re of ................ be L.iCens►No Da 19. ...... Temperature water Waa�aiemlcal analysis made? Yes❑ No . I USE ADDITIONAL SHEETS IF NECESSARY) 5 File Original and First Copy with Department of Ecology WATER Application No. WELL REPORT Second Copy—Owner's Copy Third Copy—Owner's Copy STATE OF WASHINGTON Permit No. . . (1) OWNER: Name...W.. H. .Grim...... Adderee...E ..8.070 Hwy. ...10..6 Union .WA • . (2) LOCATION OF WELL: county. Mason r. ............(; Sec...3.5. T22.. N.. R.. 3 Ww.M. searing and distance from section or subdivision corner TRS 4-5 of Lots 3 & T.L. EX__ _ __-__ _ (3) PROPOSED USE Domestic !0 WELL LOG: Industrial ❑ Municipal ❑ 10)) Irrigation D Test Well 0 Other 0 Formation: Describe by color,character,size of material and structure,and show tluckneu of aquifers and the kind and nature of the material in each stratum penetrated, w th at least one entry for each change of formation. (4 TYPE OF WORK: Owner's number of well — MATERUL FRODQ TO ) luf more than one).... . . — New well a) Method: Dug 0 Bored 0 - Deepened 0 Cable ® Driven 0 — — 0 45 Reconditioned 0 Rotary❑ Jetted CI Brown conglomorate . (5) DIMENSIONS: Diameter of well .. .. 6 inehea• Cpmpntpfl sanci�t_gr_avirl_-- ---- Drilled 90 .. n. Depth of completed well..........--•----•n with water_ �` _ ___ 45 G _ 5 .. (6) CONSTRUCTION DETAILS: Sand & gravel with water �85 90 Casing installed: .., 6 " Dlam. from .....0 .... ft. to $..5-....._ ft. Threaded❑ ... - " Diem. from . . .. ft. to ft. — _ Welded D( " Diam. from ... ....... ft. to ft. Perforations: Yes❑ No Q( —" Type of perforator used.. .. .... .._........... ....................._.......... ... .. ..... . _ SIZE of perforations :.. in. by ..-......... ._........ la. perforations from ft. to ....__._........... ft. . ........ perforations from ............._...._ ft.to .... ft. — perforations from ...... ft. to ft — Screens: Yeses No 0 Manufacturer's Name Johnson --.1a —— Tyoe...S.t.a�.nle.s.s Model No -.._--...... Diem. 5....... Slot size .6.0 from .--•.85.. ft. to 90 tt. Diem. Slot size ......... ... from ... ......... ft. to . ft A = 2 _ el Gravel packed: Yes❑ No Q size of gravel: ............................ ?— `C) _ " —__ _. Grt.vel placed from — ft. to ft. — — -_-- — Surface seal: yes No op To what depth? .........18....._. ft. — — Material used in seal........ et.QL1.1 t a ... .-- Did any strata contain unusable water? Yes❑ No❑C —.--- r- . Depth of strata .Type of water?...... ....._........ - —------— Method of sealing strata off.. _ -- —"-"i-- (7) PUMP: Manufacturer's Name 4 — H2 __ - (S) WATER LEVELS: Land_stttiace elevation above mean sea level.... .........--.tt• —.--- -Static level ... - 3 tt- below top of well Date ........... --- Artesian pressure ....... .. lbs. per square inch Date ... .................. ---- - ...... _ Artesian water is controlled y........- ...•(Cap,valve, etc.) (9) WELL TESTS: oweredwbelow statictlevlwater level is Work started........_.... . ly Completed .Marc ........ lY.. 8.7 No If yes.by whom? .. .. ...... Was a pump test made? Yes p 60 WELL DRILLER'S STATEMENT: Yield: gal./min. with ft. drawdown after his This well was drilled under my jurisdiction and this report is — true to the best of my knowledge and belie(. Recovery data (time taken as zero when pump turned off) (water level measured from well top to water level) •• - NAME.. Davis...Dri.L in�....... Time Water Level Time Water Level Time Water Level (Person, firm. or rporation) (Type or print) Addresa.H.e.LL1ai.r.� .... 98528 Date of test .._.............. ..... . [Signed] NL 4xf.?-.. • Bailer test 2-0 gal/min. with.40._.....ft. drawdowm after 1 hrs. (Well Driller) s.pxn Date 0 7 9 7 Artesian License No Date M.a.r. h....--... ., 19.8.7.. Temperature of water....... .... Was a chemical analysis made? Yes❑ No(a , (USE ADDITIONAL SHEETS IF NECESSARY) 3 wmmimw , .ww. File Original and First Copy with Department of Ecology WATER WELL REPORT Appliviation No Seoond Copy-Owner's Copy Third COPY-Drillers Copy STATE OF WASHINGTON Permit No . .. • (1) OWNEB Name Dick Buechel P.O.Box 1170, Union, Wa. — . • •••••••••• (2) LOCATION OF WELL: County Mason 22 3W - . ..... ........_.I,•4 Sec..)5 . T. ....N.. R. . W.M. Bearing and distance from section or subdivision corner (3) PROPOSED USE: Domestic 0 Industrial 0 Municipal/ (10) WELL LOG: Irrigation 0 Test Well 0 Other 0 Formation: Describe by color,character,size of materiat and structure, and show thickness of aquifers and the kind and nature of the material in each rtratum penetrated, with at lead on* entry for each thongs of fcrrmation. (4) TYPE OF WORK: Ownerstia not: be ofwell an nor ) MA MATERIAL FROM TO New well Method: Dug 0 Bored 0 — Deepened 0 Cable 0 Driven D ------• . -.— -- Reconditioned 0 Rotaryd jetted CI Sand & gravel 0 —4 _ (5) DIMENSIONS: Diameter of well 6 Hard pan 4 24 Drilled 82 ft. Depth of completed well. Bres„. Cemented gravel 24 _. 56 Bwown clay 5.611 71 _ (6) CONSTRUCTION DETAILS: Cemented gravel 71 78 Gravelkntfg________ 7-8 - 82 Casing installed: 6 .. Dim. from 0 ft. to 82 ft. — Thresidedy Mani. from tt. to Welded . " Diem. from tt. to ft. ---- ------- - Perforations: Yes D Nod ---------_ Type of perforator used... .... ..... —. --__ SIZE of perforations ..... . .... ...... in. by in. perforations from . . .•.. ...... ft. to -.....---...... ft. .-..._........-.. perforations from it. to ft • —__ • 73 .. perforations from ft. to .. - ft. 171,..,--. Screens: Yea 0 NO j ------__. -------- 1-T1 a F 7 Manufacturer's N .. = elk --- TyPe.-............................ -.........--.... Model No Alarm Slot size . from ft. to ft. -pit T1 Dlam. Slot size from ft. to ft. = -r-- r- ---- —______Fii .. _ Gravel packed: yes 0 No/ size of gravel: ...... .--• _ __________ , _..___ ._ Gravel placed frorn.....-..- ft. to ft. __ -----____-------- ..____ --- 18 Surface seal: yes 41 No 0 To what depth? ft. ------- ---- . Material used in seal ...Bentonite . _.... _ — _ — — 1— Did any strata contain unusable water? Yes CI No 0 _ _._ _ ___ _.._ Type of water? .. ... .. Depth of strata... ......... I Methong ff _—_ — (7) PUMP: Manufacturer's Name .. ------- HP. ---e --• — __—. (8) WATER LEVELS: 1...anvd; treaanceseeneavtr... . 1611.?7. ___ Static level ........13. ... . ...ft. below top of well Date ....0 ..; - Artesian presaUre - .. . lbs per square Inch Date ____ Artesian water is controlled by.. (Cap. . . valve etc 1 — -• -------- -- --------— - —_..____.__ (9) WELL TESTS: Drawdown is amount water level is lowere below static level —- - --- 07-ft --1.07f2/84 Work started • 19.. corn Pikted . 19. Was a pump test made? Yes 0 No If yes, by whom?.. . ... •.•• ....• Yield: _ gal./min. with ft. drawdown after rs.h WELL DRILLER'S STATEMENT: _ *. This well was drilled under my jUrisdictiOn and this report is - true to the best of my knowledge and belief. Recovery data clime taken as zero when pump turned off) (water level measured from well top to water level) NAME Bedell Pump & Drilling Co. Tone Water Levet Time Water Level 1 Time Water Level - - - (Person, firm, or corporation) (Type or print) ••• I 1583 E. Dickinson St. Shelton, Wa. • Address ..... I i Date of test .... .. [Signed] ..i.i:41-7-• /4feebleZe Bailer test....... 45 gal/nun. with....60 ...ft. drawdown after. i. hrs. (Well tiller) Artesian flow . _ - ...g.p In. Date 10/13/84 Temperature of water ..... . Was a chemical analysis made? Year] No f. License No 00)2 Date , 19. t tist ADDITIONAL SHEETS IF NECESSARY) 44:EgIO 3 Fife Original and First Copy with WATER WELL REPORT :Start Card No 082535 _ Department of Ecology - Second Copy-Owners Copy STATE OF WASHINGTON ThrrO Copy-Dnllerb Copy Water Right Permit No. -. i (1) OWNER: Name_ Don C. Warren -_--.- - -. Address. _9051 Hwy 116 Uni on WA 98597 - (2) LOCATION OF WELL: County Mason __ SW _n_SW`_, Sec 35 T._ 2 _N..A 3W WM. (2a) STREET ADDDRESS OF WELL (or nearest address)- (3) PROPOSED USE: IXDomestic Industrial Municipal L1 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION C Irrigation - 7 DeWater Teat Well l 1 Other LI Formation: Describe by color, character. size of material end structure, and show thickness of aquifers end the kind end nature of the matenel in each stratum penetrated, (4) TYPE OF WORK: Owmar's number el well with at least one entry for each chance of information. (if mae then one) _-- __ -. MATERIAL I FROM TO X Method: Dug - Bored I -- - _i - T Abandoned I 1 New well - Deepened Cable :X Driven . — Reconditioned Rotary ' Jetted Brown cong1omorate -.__ -_._.-___Q 2Q (5) DIMENSIONS: Diameter of well inches. 1 Drilled 58 feet. Depth of completed well 58 ft. „and & gravel with water ' 20 , 58 _ (6) CONSTRUCTION DETAILS: - -1-- -- - -,- - Casing installed: _ __6__• Dam.from 0 tt.to 51 tt- - - - _. Weded X. • Diem.from ft.to n. __ _ Liner ineulled t Threaded 1 ' Dam,from ft.t0 tt. L I Perforations: Yes El No� __ -. -- -- Tyoe of perforator used - ---- - ----- I SIZE of pertriatlens— - _-- in.by - __ In. i -_perforations from__ _ _.ft to it -_ I 4- 1 perforations from_ ft to -- h. - - II Screens: Yes No perforations front ft to ft• 1 o f 1 Manufacturer's Name Cook _ -. -- -- --- - - — Type stainless Model No Diem 5j 1 t 53 n.td 58 n. 1 r Slot ease 40_ _from .. _ . __-_-_ _ - I __ Dam Slot size from ft to n. i _ �7 11 I Gravel packed: Yea❑ NoI�I sae of gravel Gravel placed from tt��I 11 ft to 18 ft. Surface seer: Yee 11i1 NO lLJ To whet depth? tt. T Material used in seal. Betonite , Did any strata contam unusable water? Yes L1 NoCII . Type of water? —Depth of strata _. -- I -- .._ . -- - Method of seslrng strata off -- --- -- - -(7) PUMP: Manufacturer's Name Grundfos - • - - _ type•-_ SUb. _— --H.p -- -- I 4 - Land-aurtaeeele•aaoa 1 ----- (8} WATER LEVELS: above mean see level_ ft --" -------- i Static level 13 ft below top of welt Dole -- ' - I Artesian pressure lbs.per square inch Date- -_- - - - ----:- i Artesian wafer ve controlled by-- (Cap valve.arc)) - J Work sinned 11/3/91-...19 Completed- 11/7/91 _. 19_. (9) WELL TESTS: Drawdown is amount water I..vei is lowered below static level Was a pump teal made?Yes Li No131 it yea.by whom? WELL CONSTRUCTOR CERTIFICATION: Yield gal /mtn.wnh ____--._ tt drawdownaner his. I constructed and/or accept responsibility for construction of this well. and da compliance with all Washington well construction standards. -" .. Materials used and the information reported above are true to my best Recovery date(lime taken as zero when pump turned oft)(water Myer measured knowledge and belief l tom well top to water level) •,-r Water Level T..ma Water Le.el Tine Water Level AME-. _Davis8Drilling -1S (PERSON FIRM. OR CORD RATION) (TYPE OR PRINTI Address Belfar WA 98528 - Date of test - - (Signed) License No. 0797 Bailer test _-1Q-.gel t min with_7___—It drewdown after -- hrs. ( L DRILLER) Contractor's Autest __-_-gat.,min with%l fin set at. It for hre Nego.OttalplADI1100A Date Nov. . 19Z1_ Artes,an tlow - - -_--_g p m Date r Tempe,aluteolwater-_- Was achem,eelenelyeismade? YesL1 No U(I (USE ADDITIONAL SHEETS IF NECESSARY) A