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HomeMy WebLinkAboutWEL2023-00022 - WEL Application, Design, Letter - 4/19/2023 eiMe; MASON COUNTY 415 N 6TH STREET,SHELT967 ,E 98400 SHSTREE ,S 42 TON, ,EXT 584 BELFAIR:360-275-4467, EXT 400 f Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 KOBERSTEIN DAVID R & TERRI L 8815 71ST AVE NW GIG HARBOR, WA 98332 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL 2023-00022 XCKXX NE Tahuya Blacksmith Rd 223305000205 The 2-party water system, Koberstein/Linden Water System (223305000205/223305000204), 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 72q/ zoz5 • ray _. Date Received, 7 / //I/�f/yI///�/}Zi MASON COUNTY (J COMMUNITY SERVICES Amount Received: Rec eived By e, .' Building.Ptatnatg.Environmental Health.Community Health (t 415 N.6'"Street,(Bldg 8)-Shelton,WA 98584 WE L to 7? - Oro ? Z Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPI.IC.ANT PIIONE. 3149J— Ol-4137$- Dc� L0 er5w '� Co fir-Ill *ZrAvi5 Dn`Ili MA ANC ADDRESS CITY.S]'ATF ZIP � 3IS ! 1 s+ • V 611' He`I/-b`J( W P\ -I V j 3 2 SITE ADDRESS-STREET,CITY,STATE,ZIP � " 2 I CA S. of (Sa v NE —rcol v A -a CcAc kSn-t tJ.-, I sec ven LAke PRIMARY PARCEL NUMBER(WELL SITE.) 223)-S0 -- 00 ZUS SECONDARY PARCEL NUMBER(SAME AS PRIMARY/IF LOCATED ON SAME PARCEL) Alen 'n Ater S /4 )('' w22 33u- Sa m 00 L./ SOURCE TVPE lot SKiripveelEL I tOT 1177 eif •e1�Rmin I acre) PKRCEL2LOJ(` I j'1�LJATER SOURCE T SIZE(min I acre) )(New E Existing .Jell Li Spring 2 1 (r e !�l qr) , ZS PROPOSED WATER SYSTEM AME.(REQUIRED). + kob rS-�-e L.I.etdLe;, wA{e r s ys1 e V PROJECT DESCRIPTION(e.g.,detached AUC,new single-family residence,existing connection,etc.) 2 _cc,.c-1-( �e 1 I DIRECTIONS TO SITE(CONDITIONS)GATE CODE.I KEY LOCATION/ETC. 1- Iof S- of- 1006 NE 7ah( a '3Iack- 0r men La4z 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) El 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 Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office 5. Septic Records(additional locatin requirem is may apply if there is a lack of septic records on file) �7 i`n� C v n ck SS'e Revised:01//2025 This form may scan a made availab for public viewing on the Mason County website. Page 1 of 2 maa, Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ pi 0 Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) ❑ ri 0 Are there roads within a 100-foot radius of the water source? Is the road Private,County,or State?(circle one) Distance to the road(s) ❑ Does the ground slope away from the water source site? ❑ Satisfactory well cap? 0 0 Well cap screened and vented? 0 The well casing extends ( L above level d/ ncrete slab?(circle one) NI ❑ 0 Evidence of a surface seal? Lat: 4}•4f f f t J2-' 0 0 Adequate surface seal? Lon:-I L 1.9g?Zf ❑ ❑ Variance necessary for well site approval? Tag: PPO if y Comments: we(' pre .( ic p c ,4S SCOt , sir i 70 Z, 40 '-- ;31 Pass 0 Fail Inspector /a Date b/ ?0,0?J Review Step 2: Two-Party Review: YES NO NA ® ❑ ❑ Water well report(well log)with a concurrent capacity test? AU) 0v'%'II tll f 04 !//rm y V/ 17 bPor fhe6011447, Tr ❑ 0 Nonconcurrent/separate capacity test? /� Capacity test information: Date i( id /� 5/( j yDriller uK i Dwl!{/ J,), • GPM /Y Duration(minutes) ` ?0 Total Gal ?o —( U 85 ❑ 0 Satisfactory bacteriological analysis? Date of test f.?f/td Z ( d ro owners?AFN Z Z z l9 � ❑ ❑ Signed,notarized,and recorded notice to future property 10 �' ❑ 0 The system appears adequate to serve two connections based on the information provided�uN VF D Comments: 7), oil, , wfNjA� (kf Approved ❑ Denied Reviewer / 1 , Date R ' z02Sn, 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. Pagc 2 of 2 • WATER WELL REPORT ii DEPARTMENT Of NoticeoflntentNo. WE52450 . ECOLOGY Unique Ecology Well ID Tag No. BPQ114 Type of Work: State of Washington O Construction Site Well Name(if more than one well): ❑ Decommission Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ❑a Domestic ❑Industrial 0 Municipal Property Owner Name Dave Koberstein 0 Dewatering 0 Irrigation ❑'lost Well 0 Other Well Street Address NE Tahuya Blacksmith Rd Construction Type: Method: (j Tahuya County Mason a❑New well 0 Alteration ❑Driven 0 Jetted I Cable Tool h' 0 Deepening ❑Other ❑Dug 0 Air- ❑Mud-Rotary Tax Parcel No. 22330-50-00205 Dimensions: Diameter of boring 6"to 5" in.,to 194 ft. Was a variance approved for this well? ❑Yes ❑No Depth of completed well 194 ft. If yes,what was the variance for9 Construction Details: Wall Casing Liner Diameter Front To Thickness Steel PVC Welded Thread p 1 ❑ 6 in. 0 151 1/4 in. O 1 ❑ O 1 ❑ Location(see instructions on page 2): ❑WWM or 0 EWM III 1 0 5 in. +1 189 1l4 jn. O 1 0 0 I 0 NE 14-/of the NW ''A;Section 30 Township 23N Range 2W ❑ 1 ❑ in. _ in. ❑ 1 ❑ ❑ 1 ❑0 1 El in. in. El 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.4601332 Longitude(Example:-120.12345) -122.9875593 Perforation: ❑Yes ❑No Type of perforator used Driller's Log/Construction or Decommission Procedure No.of perforations_ Size of perforations_in.by_in. Formation:Describe by color,character,size of material and structure,and the kind and Perforated from_ft.to_ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: L l Yes ❑No I K-Packer r—) Depth 186 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Material From '1'o Type stainless Model No. 2 Diameter 4 in. Slot size 72 in.from 189 ft.to 194 fi. Topsoil Diameter in. Slot sizc is from ft.to ft. Light brown silts some clay wet 2 35 Light brown clay bound gravel wet 35 54 Sand/Filter pack:0 Yes ❑No Size of pack material in. Blue clay 54 60 Materials placed from_ft.to_ft. 60 69 Grey hard pan wet Surface Seal: a❑Yes ❑No To what depth? 18 ft. Yellow conglomerate wet 69 70 Material used in seal benlonite 70 150 Brown glacial till Did any strata contain unusable water? ❑Yes 0 No 150 190 Type of water? Depth of strata Brown large gravel wet Method of sealing strata oft' Brown sand&gravel wb 190 194 Pump: Manufacturer's Name grundfos Type: Sub H.P. 1 Pump intake depth:160 ft. Designed flow rate: 12 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing_ ft.above ground surface Static water level 131.3' ft.below top of well casing Date Artesian pressure_lbs.per square inch Date 6"casing would not advance past 159' Artesian water is controlled by (cap,valve,etc.) pulled 6"casing back to 151'and set 5"inside welded 6"to 5"at 1.5' Well Tests: Was a pumping test performed? 0 No ❑Yes c> by whom? Yield gpm with_ft.drawdown after_hrs. Yield_gpm with_ft.drawdown after_hrs. Yield _gpm with ft.drawdown after hrs. Recovery data(time-zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test 17 gpnt with 10 ft.drawdown after 1 hrs. Air test _gpm with stein set at ft.for hrs. - Date Artesian flow gpm _ Temperature of water_°F Was a chemical analysis made? ❑Yes ❑No Start Date 3/10/24 Completed Date 5/19/24 WELL CONSTRUCTION CERTIFICATION: I 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 my best knowledge and belief. ❑a Driller 0 Trainee 0 PE-Print Name Emily Davis Drilling Company Davis Drilling Signature — , v -- Address 340 NE Davis Farm Rd License No. 3142 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No. DAVISDI1100A Date May 2024 ECY 050-1-20(Rev 08/19)If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. 5(Irtil0 (7/ Davis Drilling 340 NE Davis Farm Rd Belfair, WA 98528 Test Pump for: Koberstein/Linden Water System Well depth: 194' Well tag: BPQ 114 Pump size: 1 hp Grundfos Static water level: 131.3' TIME WATER LEVEL GPM 5m 140' 17 30m 141.7' 17 1h 141.7' 17 2h 141.7' 17 RECOVERY 1m 133.5' 2m 131.7' 3m 131.3' 26276 Twelve Trees Ln NW Ste.0 Poulsbo,WA ;. 98370 (360)779-5141 ' ' ' Date Sample Collected Time Sample County h 12.01 Lo 2./14 Collected Y :00 °"M Munn Day Yew rit" CiJ•vh Type of Water System(check only one bar) ❑Group A ❑Group B kotherc r I 'f 1 Q Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: O4 VC p c'v".!• Contact Person: kr e Day Phone:(?(c.) ( - Z(y 7 Cell Phone: Email: Eve.Phone: Send results b:(Pelt lug mum,addles and zip cods or small above for electronic copy of results) J e f Sample collected by(name): 'Grr f� . Specific location where sample collected(: Special instructions or comments I ' " tic44 • 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AlP) Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample ————— Unsatisfactory routine collect date: 1st I I Chlorinated:Yes,No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment(AIP) 4.Surface or GWI Raw Source Water Sample(Enumeration) S 0 E.E.coif ❑Fecal Furor Yes_No 5.a Sample CWryed for rdormatIon Only ❑Unkrttiilattory totet •Priesent and 11 Satisfactory ❑E.coipresent ❑E.co6 absent Bacteripl Density Results:Total C m olifore a mpri/10om1.E.col mpn/100n Fecal Colifam cfu/100m1. HPC cfu/lml. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container 0 Date/Time Received: Lab Reference Numb9r `; �_ Zvi 23�� .� c�'\ Recelpt Temp C': Method Codes- (SM92238/�T•000NT/SM9222D M Date In: Da Out nee/wowlaeuWeaTaJ6gr'msenepr.nweenpmyq MAY 211024 MAY 2 2 7(124 agrd rbeM Mums me^^ru.6ay eer on.e QS gri rgwely hr dotter moat cravatDOH Lab-Sample# retest Wed 010• r«a dbylmrbaaurbrMwnepatMeiwa aemelr Infutelgraa aria.prawed$n email by Syw,a ta.erra o DOH ram a1J,J,1(eaa,N.tlr1>) 1a 2226261 MASON CO WA 06/03/2025 02 53 PM NOTCE 11 I1II IIIIi 111111I 11111 Illi III III 11111 II II III 1E I'Return To 2 II Dav 'J R• kbrr5''e'n 601571st Ave (-' 3 1- 4rho✓1 uWf) 40334 Grantor(s): (1) Dav/ 41 P. <o6ers4e n (2) Ter✓' L • 4.) . rs e� n Grantee(s): (1) PUBLIC Legal Description (1) Ha Ye La Le-•l r .e.+ ZCS 5e ±io0 3c/ TZ3 Ai) IQ 2 (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 7_Z 3 -2,o - S v - 00 Z a 5 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 Assessor's 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) Z23 3 0 - Sv -vU Zo 5 Tax Parcel: (Connection 2) 22 330 - 5.4-) 00264 The system owner is responsible for keeping this system in co:npliance. The name of the water system is: !Kobe r s 4-e /L►rlde r W oia- • I Si s+e r, This system is designed to provide for two service connections..Pianning 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 Eccingy, is required if the water system exceeds exemption standards. This system (has/Es-Do been granted one or more waivers from specific provisions of the regulations. Dated on this 1 3 fi4,day of M u 7 , 20 25 Signature of Grantor(s): (1) `CAA-vi ` !%C, � , (2)d,Q0ti✓�, State of Washington County of QktcCe I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this CO' day of PA a , 20 is PaV a4.Tu'r;1441,btrs-tVin Oiersonally appeared before me, who is known to be signer of the above instrument, and acknowledged that he e) (they) signed it. GIVEN under my hand and official seal the day and y r las hove written. •••"V111111 J��,1$r W/ 11 Not ry ublic ir. and for the State of Washington, Q„lit• f4N e+�'t,`f �i res g at Pi.( c� � N My commission expires: � I [ 2°` of 26012338 060, f? 1/h t,1 q.Z �.- �4 s /i -OF wAsVo 1 ' 2226261 Page 2 of 2 06/03/2025 02:53:14 PM Mason County, WA • 4 ,Z 9 ilk *I- 2 2330- so-o6z • i + IJE T 1 (it1 Ar1M �KR • I � U ` _ 14 ,ate wa c L M 1 it 1 I th to' I co/Anp.c. cot4- ,1 i r ` `_ 1� ,1 tti • In, � �_ >.�aa[� • j �� _.GSZ�_ i ".1 jrfJ s 7� ( i �7� P.f?.l 1. f ? i ' is }• .: I\ I w tom. � �Ct�lCiwB 1 �'`S t J y� i Srlr�J ,i s . . ,_,1-�i� 0t"— {-o 'i. 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Complete Part 1. Incomplete applications will be rejected. o,C�� _ 0 Cash 2. Attach a detailed plot plan. 0 Check 3. Clearly stake out or flag the well site. CAW.0)c9, 4. Submit application and appropriate fee to Mason County Date of Payment Public Health. Refer to Mason county Environmental Healed ' Fee schedule for cost. PART 1:Applicant!Parcel Identification ` , Water System Name ber �In // Li v r' v V S Site Address N 6 Tct kl L,-)� 13 icalLLWu' j/\ Mkt L' Applicant tyAJ i d Y©l[rs-{-U V Phone 2S-3-2'S n � —/S71/ " � l� Mailing Address � �� � 1� s� / � City 6 9(r v`r be r State V V k Zip 61 B33 2 Parcel Number 223 O O 0 0 2tCS — 1 �, {,, Directions to Site 1 t 0_1 Salt h Of CS � ac,1'Lll 1 pyk TF'`e'r) 1 Water Source Is: [)New ❑Existing System Type: (11 Well 0 Spring No.of Proposed Connections Z We 40: Jv frt<c wale"' 1 ' PART 2:Health Department Review(Staff Use Only) � hIt 9r' YES NO NA Loom t?o�Jy t t.11J a�ttf 1 190, IQO' flI Vy w,#A ?S d,. of existingsources of contamination w in 100 ft ,1i radius o1 wa�er sou ce ,ll+�` � � 0 0 Evidence t (drainfields, tanks, buildings; indicate distance on plot plan) 0 (Z 0 Are there roads within the 100 foot radius of the water source?If so, is road .,1 ilnoVtD What is distance to ROW? 143 A L0 ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ 0 Z Is the well cap satisfactory? MAY 2 2 2023 i 0 ❑ to Screened and vented? �NTALHEALTH Z The well casing extends above level ground I con 8 r r` ❑ 0 ® Is there evidence of a surface seal? Lei': bl !{tOtStfII �SH ❑ 0 1A Does the seal appear adequate? an ' -(LZ• 91i7ZYt{ 7.01111P f--}- LA Is a variance necessary for well site approval? Comments fk .Yjnelccl vet! file Q, C*.1 10 be _with 7S'of Sfff%c diraMMtld ail p (41 zz33o10o0ZO5. WA on5/771dz : Wu Ibcakm mttAL cli S0/6Li refv'(cOla,ts .7? Pass 0 Fail Inspector Date 3 5//� This form may be scan nd available ter public trlew on the Mason Cnuntrulliab site. Firstlings in this review robot observed condlioos as they erdssst ift S ll! -its deim is ldre fusee wooers or More of this Weil Sas passage does not constants weer system approval.Waist system approved is a two pert pie ess. 1)Passage dew welts praiM of the weer syMsm dsslgt.Once the wall side Ippesss4 the weer spasm dwgn rosy be srrbmflled ter review • J:TH Forms\DRINKING WATER FORMS\Drinking Water Wcil Site Inspection App.docx Revised: 1,20/2017 Printed From Mason County D-: Printed from Mason County DMS o Z s ,... ..... ?r -fi()Pe 6.11 , ,---1 4 __ .. .. , ,. .,. , .........., . ,.. . • _ . 1 . ...... ,.„, , )8 ,A ,. ts cA - 1AP , Rs 4 4.illa ‘ 1 . , , . 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