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HomeMy WebLinkAboutWEL2025-00029 - WEL Application, Design, Letter - 5/30/2025 (2) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 riA BELFAIR:360-275-4467, EXT 400 f� Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 FAGUE TODD C & HOLLY M 780 E ISLAND LAKE DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00029 782 E Island Lake Dr 320065004002 The 2-party water system, Richard Water System (320065004002/320065004003), 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 Date Received- E � MASON COUNTYSERVICES �_-�^ c�� COMMUNITY Amount veQ l Recei ed pj 1e0 • &rilding Planning Environmental Health,Community Health (�� / J� 415 N.6'h Street,(Bldg 8)—Shelton,WA 98584 •�/��EL vL/C (3+5 ` 5 ©cp_51 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PHONF', �Y �s �,/�1J APPLICANT D r,� I _ 71 �33Y� 7• _ M AILING ADDRESS-STREET,CITY Sl':CI'E,71 !_`y ca . l�p 1 q te! (����"Cf���J, f r�i'(//'jrJ l/1JAv1 SIII:.ADDRES-STREET.CITY,STATE,'/,IP Q���� YL2� rG -�.D �� Da- , -V PRIMA PARC EL NUMBER I\N ELL S kr, — — Q Lb Cr)7-- sr,,CONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SASE:PARCEL)IW.. I) rW AI 7075-,.ollo 3 1 S vs:YI'ER SOURCE I SOURCE TYPE PARRS I.I LOT SI7,k:(minI acre) PARCEL 2 LOT SIZE(min I acre) / ,. ^ New Axisting �Cw'ell Spring I • q 1�.(fV',(,�/5 ! 67 PROPOSED WATER SYST M NAME(REQUIRED). .ic -i-r u13,3--na--- /T /i4 PROJECT DESCRIPTION(e.g..detached ADC,nrw single-famil)residence,edding connection,rtr.l � I r _ 7-t�Uc� ��42� L ///P/Y���"`///T^^^yyylLL,� ((ni((/• [�J[1���/Av,(�'L DIRECTIONS TO SITE I CONDITIONS/GATE CODE/KEY LOCATION/ETC. /A-1- I ^/ /7- iiAl 00ce tc. of- 10) , 711/Ze Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer componen - -nd lines,wa easements,etc.) ` -r lines.property "Pc<'cF2 ??01,5 w i==7 FO g • w 0, O ,,,,I N O CJ1 M 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 Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditors Office 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 of2 ------------------------------------ Staff Use Only ------------------------------- Review Step 1: Well Site Inspection: YES NO NA Egg ❑ 0 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 with' a 10-foot radius of the water source? Is the road Private,1 oun ,or State?(circle one) Distance to the road(s) O /I: 0 0 Does the ground o.- away from the water source site? ❑ ❑ Satisfactory well cap? ❑ ❑ Well cap screened and vented? • ❑ The well casing extends I? above level ground/concrete slab?(circle one) 0 Evidence of a surface seal? Lat: `{7.2-N g(Pi xi El❑ ❑ Adequate surface seal? Lon: -In.,1 L6O 0 p 0 Variance necessary for well site approval? Tag: A LL 21 Z. Comments: / Pass El Fail Inspector / Date (/ZL(t/20l.r • Review Step 2: Two-Party Review: 21 p �ff,,,,,,-- ,,---- YES NO NA Ir�� repot l(ONO5, PO P iejfOr w ❑ Water well report(well log)with a concurrent capacitytest? 0 ❑ Nonconcurrent/separate capacity test? Alk �,�y , (� Capacity test information: Date 6 4 Driller f1 <<lcAiy`t 0n 111)7 GPM Duration(minutes) 15 Total Gal V CO 0 ❑ Satisfactory bacteriological analysis? Date of test L(l 30/ 707 J ❑ ElSigned,not arized, (. " l and recorded notice to future property owners?AFN 36 A d i) 7 ❑ ❑ The system appears adequate to serve two connections based on the information provided? Ofr Comments: ��9SO�C0047),✓U` 08 0 ?pis Approved ❑ Denied Reviewer / - Date 0 yF4, 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 0 a a/ tt CURRENT — WATER WELL REPORT Notice of Intent No. WI 97�78 , Original&l"copy-Ecology,2"a copy-owner,3"copy-driller ' " Unique Ecology Well ID Tag No. ALL322 E C OsL 0 G'T• to CoConstruction commission ("x"in circle) Water Right Permit No.EXEMPT WELL CConstruction GARY WILSON +-r Decommission ORIGINAL INSTALLATION Notice Property Owner Name O ( 777 „ of Intent Number Well Street Address 780 E.ISLAND LAKE DRIVE C PROPOSED USE: m Domestic 0 Industrial ❑ Municipal City SHELTON County MASON O ❑DcWaler ❑Irrigation ❑Test Well ❑Other'47, NE SE 1 201 4W etvnf ❑cirdc Location 1/4-1/41/4 Sec_ Twn R Or ❑�e m i TYPE OF WORK: Owner's number of well(if more than one) wtvbf E 0 New well ❑Reconditioned Method:❑Dug 0 Bored 0 Driven Lat/Long(s,t,r Lat Deg Lat Min/Sec El 0 Cable 0Rotary ❑Jetted O DIMENSIONS: Diameter of well 6 aches,drilled 80 fl. Still REQUIRED) Long Deg Long Min/Sec = Depth of completed well_8.0 ___ Tax Parcel No. 320o65ooaoo2 -- CD CONSTRUCTION DETAILS -C Casiag m Welded 6 " Diam.from +2 ft_to 80 ft. 4-t Installed: Liner installed " Diam.from ft.to ft. CONSTRUCTION OR DECOMMISSION PROCEDURE ®Threaded " Diam from ft.to —ft' Formation: Describe by color,character,size of material and structure,and the kind and Perforations: ❑Yes mNo nature of the material in each stratum penetrated,with at least one entry for each change of TS Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY.) MATERIAL FROM TO C SIZE of perfs in.by in.and no.of perrsfrom_ft.to^ft. I S RI 0 K-Pac Location DARK BROWN SILTY GRAVEL 0 Screens: ❑Yes m No15 41 �.r Manufacturer's Name BROWN SILT BOUND SAND,GRAVEL RI Model No. LOOSE GRAVEL AND WATER 41 58 O Type Diem. Slot size from ft.to ft. Diam. Slot size from ft.to ft. GRAVEL,SOME SAND AND WATER 58 80 Gravel/Filter packed:❑Yes m No 0 Size of gravel/sand ••110 Materials placed from ft.to R. 4a Surface Seal:0Yes ❑No To what depth?20 ft. =CCI Material used in seal BENTONITE CHIPS LL. Did any strata contain unusable water? 0 Yes l;a No R Type of water? —Dept h of strata 3 Method of sealing strata off l'' PUMP: Manufacturer's Name OType. H.P. Z WATER LEVELS: Land-surface elevation above man sea level ft. y Static level 36 ft.below top of well Date 11/16/04 W Artesian pressure lbs.per square inch Date 0 Artesian water is controlled by 'C (cam valve,etc.) WELL TESTS: Drawdown is amount water level is lowered below static level v OWas a pump test made?❑Yes m No If yes,by whom? rs. G Yield: _ga1./min.with R.drawdown after Ices. Yield: Rat/min with R.drawdown rafter hrs. I __ . — ` t LI Yield: gal./min.with ft.drawdown after h _ W Recovery data(time taken as zero when pump turned o•)(water level measured from well 0 I top to warn level) Y '�,, Time Water Level Time Water Level Time Water Level W — - '0 d f-, CD E - w . I. Date of test kii CU Bailer test gal./mm.with fl.drawdown after hrs. . CLAirtest 26 gal./min.with stem set at 70 ft.for 1 1us. - a) Artesian flow g.p.m. Date 0 Temperature of water Was a chemical analysis made? ❑Yes m No4.1 Completed Date 11/16/05 Start Date 11/16/05 P t - I— 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 ARCAtrue DIA IA DRI my bestLLING Idge and belief. ED NE_LSON Drilling Company NC. O Driller ❑Engineer 0 Trainee Name(Pri Address PO BOX 1790 Driller/Engineer/Trainee Signature ( P' _ SHELTON WA 98584 Driller or trainee License No. 1886 City,State,Zip Contractor's If TRAINEE ARCADD1098K1 _pate 1 U17i05 Registration No. Driller's Licensed Na. Ecology is an Equal Opportunity Employer Drifter's Signature ECY 050-1-20(Rev 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Todd Fague Well Tag#: ALL322 Site Address: 782 E Island Lake Dr, Shelton Depth: 80' Date of Test: 6/24125 Static: 36' Pump Set: 70' TIME GPM LEVEL RECOVERY 1 Min 20 42 TIME LEVEL 2 Min 20 43.2 1 Min 37.5 3 Min 20 43.5 2 Min 36.3 4 Min 20 43.6 3 Min 36 5 Min 20 43.7 6 Min 20 43.8 7 Min 20 43.8 8 Min 20 43.8 9 Min 20 43.8 10 Min 20 43.8 15 Min 20 43.8 20 Min 20 43.8 25 Min 20 43.8 �/L, 30 Min 20 43.8 zz// 40 Min 20 43.8 �/N435 Min 20 43.8 6 2025 45 Min 20 43.8 1?ECFI1/ 0 'Total Gallons Pumped: 900 Gallons I I v] 1 v anguarci Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 yeoaeaII 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected D ❑�, MASON 04/29/2025 ®PM Month Day Year Type of Water System(check only one box) • ❑Group A ❑Group B I]Other Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: TODD FAGUE'\Q,KA-4242,0 ulaA-rk2 • Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results to:(Print full name.address and zip code or e-mail) artetagarcadiadrilling.com AND lennriarcadiadrillin9.com SAMPLE INFORMATION Sample collected by(name):MAX Specific location where sample collected: Special instructions or comments: 782 E Island Lk Dr, Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(NP) 2.❑ Repeat Sample(A/P) 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 cdlect date: S � — I Chlorinated:Yes No ❑Triggered(NP) Chlorine Residual:Total Free ❑Assessment (ANP) 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.colt ❑Fecal F.irered Yes._No _ 5.I]Sampe Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Jit1 Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform 1100m1. E.coli /100m1. Fecal Coliform /100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/Time R eived Lab Reference Number Receipt TempC°. Method Code. SM9223B Date Reported to DOH Lab Use Only. DOH Lab-Sampled 285- 43019 DOH Fdma331J'9(dreche C5'?,.5?Da mad eep rn an YMN9A forme.cal 800 525 0127(7uonnn call n1) 2227612oT�MASON CO WA 07/07/2025 CONKLIN 11211488 Rec Fee. $304.50 Poses. 2 Return To !►1111111111�n11111f1111111l1I111111111111III 1111111Ib11111111 C A 4,4 Iksc � 5 i 0 GraaGor(s):(1) pD L. Hut._ ,(2) 44[] Al- F Grantee(*(I)Pp 1-26R. 3 Legal Description(I) M -c- i t OP vet.. Za3-3�i (Abbreviaeetdfarsc Le.lot.block,p or se ion.township.range) Assessor's Tax Parcel:(1) 2,Q�aC)(? -- -' ts7 400 2. NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I(We)the undersigned grantor(s),certify that the water source Iocated 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 I) G - tr:Jc'ter:i0 7-- Tax Parcel:(Connection 2) - --- 4"On The system owner is responsible for keeping this system in compliance. The name of the water system is: c4-1-'&-f7 1/ -4a- 'Ibis 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 froth specific provisions of the regulations. G i Dated on this a. \ day of M •20 a 5 Signature of Grantor(s)- (1) /ate C. .C2) Page I of 2 State of Washington County of Mason I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that o this day of r(1 ,20-2.5 , 1 Cab 6 6. petsniially appeared before me,who is known to be signer of the above ins ent, t?d acknowledged that they signed it_ GIVEN under my hand and official seal the day and year last above written. 6-111\74:2-- -g-a____ .`''� EZE NF•,p�'°,, Notary Public and for the State of Washington, o` fires ,o Q tr�P 1?i62-0. residing ��=�1. Q �Q-:� NOTA R y _ My connmission expires: 1 �Q' R o PUBLIC IISS ';;AT)..:Ns I o n$21�\�C'�; N 0F WAS Page 2 of 2 2227612 Page 2 of 2 07/07/2025 11:49:32 AM Mason County, WA N is,-�.-, 6 i > to .54. i ti0 10t05' ( ././. to I i 7 • m D i r 7J 1..) 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A 4: CO Z cc, I CO CO W -P. n 0 r' n N Z N W cn m (A —� c� (/) D o cn • i �- o m ;n -3 Z cn .n S� m Q Ch N 1 W A O rTl N N A A. 0 A• IV A N IV 00 • N i {V ;Jo.. 1 I I I j I I SASI Z R)N t5 • ;E'4Rl To 2 NG W l l M)N t5`2215., . 180 00, • • E i C* \ . 0 30 -��d'� , / w • °.`c ENE 4 / Nty°., '• • ~ O t3' • 66�r N � � p wqC� 9925, zrn � � co 1� 1C t �CFSS ISLAND R t • y,<\�Op� li cxl ivE• > I ' t5' �48 � 1 0 0 X C 9 S2-11 �` �\ C6 `� '�0 r n m to co f 0 r 99.03. _ <.� c DR LAND SURVEYING PLLC EXHIBIT PROFESSIONAL LAND SURVEYING EXHIBIT FOR WELL AND DRAINFIELD LOCATIONS 222 SE SNIDER RD SHELTON,WA.98584 5 7 2025 (360)427-8392 drsurveying@yahoo.com 400.72' S 88°39'55"W 41145 SqFt a 0.94 Acres o o `, s ^ N \c� O�v -. ko ` 10�FtP s69 00• ��S�\�G ' DRAIN FIELD 424.31' i 5g. 158.4 - N 88°51'43" E 1 I 1 38014 SqFt 0.87 Acres • • N 88°52'53" E 322.63' ii ff .,2.1%,Y M OHO .s5) ojf�"ASy� 4 `i, Q a" i yco 51 NOTE:THIS IS NOTA SURVEY ,©� O f. ,r. z FOR ILUSTRATIVE c `' F PURPOSES ONLY 44645�0 S cIST0. JQ' s'0/v4 L L M 0 50' JOB:2025-024 =_� BASE-$$SURVEYNAME INDEX:NE1/4 SE 1/4 AND SE1/4 SE1/4 AT FULL SCALE,IF NOT ONE INCH SEC. 01,T2ON,R4W,W.M. SCALE ACCORDINGLY MASON COUNTY STATE OF WASHINGTON Traverse PC —_______ 8 r� I g ug ri. . cc u' w w -- w Z w 0 CD u) Q a 2 j N Z a co # H to 2 w m Q al 43 U N 8 0 !f! irit..,...3 n_ , in • g Z �3 O x rn iE cc Jr� J Q Ili r � SU ~ F- tpl I tmt u. a- mZ . � cc ii icy) gym , Ioo �.�'tir �i w/0 1�F���. rtU W ?- . 1 tr 1 1� g Z ,Mrs',,'.()vED o tnT OCT 19 2005 r w ....Evi ia 4 iJ '0 Qv O >I -70 Z Z j_ 0 z 0 .JJ T ` W 2- Q d W <<KI 0 cc3 i 0