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HomeMy WebLinkAboutWEL2025-00029 - WEL Application, Design, Letter - 5/30/2025 rgOil MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON: 42 ,EXT 400 584 BELFAIR:360-275-4467,EXT 400 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 MASON COUNTY Date Received ^ . COMMUNITY SERVICES Amount{��r1J1 Receivedffi^ Building,Planning Environmental Health,Community Health e/�iG D `Vj/J� r 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 WEL ( c3,5 - V co(D_51, Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 -.:__ TWO-PARTY PRIVATE WATER SYSTEM APPLICATION --- . .APPLICANT . PHONE . er-[ ID PC) T 1Al1.ING ADDRESS-STREET,( L tLLl0E 6 ik- Pa ' e ' -e — .7 e(, SrrE ADDRESS- FT, .STATE.ZIP /� � G� Da- qr-JXI,�v) PRIMA 1'PARCEL NUMBER(WELL SrrE) tZ1 :;if7(3 — _ otbe--/DZ SECONDARY PARCEL NUMBER(SAMEASS PRIM RY IF LOCATED ON SAME PARCEL) I'.`!1I/177S- 0003) 1 v IY.CI'F:R SOURCE SOI RCP:II PE PAR .1.I LOT till:(nuv I acre) P:\RCF.1.2 LOT SIZE(min I acre) New )xisting ).Well Spring . q !mil Vas e 67 PROPOSED WATER SYsi M NAME(REQUIRED). 44i6.17/ ) 023/9� 77 `�./t1 PROJECT DESCRIPTION(e.g..detached ADO,new single-family residence,existiinng connection.etc.) rba-e I _,5 DIRECTIONSTO SIpa /GATE 'ODE/KEY LOCATION/FTC. m • ice Veep 17 / /AIA4/ �..,(�UPlyi�0%-ice tJ1£,L LL . l ::e Site Plan: (may also be attached)(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer componen • .nd lines,wa -r lines,properlyeasements,etc.) 4Z<•C�iG ?-, 07 FQ g • W o b IV c4 t= IV V v Required Submittals Checklist: (additional information located on the first page of this packet) 4 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 Septic Records(additional locating requirements may apply if there is a lack of septic records on file) "['hi form may be scanned and made available for public viewing on the Mason County website. Revised:01//2025 Page 1 of 2 — - StaffUseOnly ---- -- - — — — -- — _ - - E- -rY. =sax:•- .- -.. ..,.a...-..a« e.-:-.. -e..: --- A __.__ ..-.__— -...- . .__._.T___-.... --_._ Review Step 1: Well Site Inspection: itlit YES NO NA ❑ ❑ 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? 41.r Is the road Private,' ount ,or State?(circle one) Distance to the road(s;"—c0 ❑ ❑ Does the ground o.• away from the water source site? ❑ ❑ Satisfactory well cap? ❑ ❑ Well cap screened and vented? 7 ❑ The well casing extends 7 above level ground/concrete slab?(circle one) ❑ ❑ Evidence of a surface seal? Lat: 4 7,Z N S 4 N yl El Adequate surface seal? Lon: `l 2 3.1 t -60 0 ❑ Variance necessary for well site approval? Tag: ALL � 2 Comments: piPass ❑ Fail Inspector � Date b/z f f 20l,1 Review Step 2: Two-Party Review: YES NO NA 0 ❑ report(welllog) capacity4fi�t report I(f/�C(�S. No po 16far d Water well with a concurrent ca aci test? f ❑ Nonconcurrent/separate capacity test? 415 9 / , /� Capacity test information: Date 6a It ZOl5Dri ller t(l(/t I 'yt 0 PI It�) GPM ZO Duration(minutes) YS Total Gal fG"O 14 ❑ ❑ Satisfactory bacteriological analysis? Date of test '1 30/ 2075. O ❑ Signed,notarized,and recorded notice to future property owners?AFN 1. 7-7361I , ❑ ❑ The system appears adequate to serve two connections based on the information provided? I_ o tt'' Comments: /�9s0'1'CpU ✓UC �8 Nry cpes iki Approved ❑ Denied Reviewer Date o -40 if 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 19th, 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 4-; I` 0 t2 Ct WATER WELL REPORT CURRENT '' CO' OriginaCI) l&l"copy-Ecology,Y'a copy-owner,3"copy-driller Notice of Intent No. WI 92378 S i c o c r. Unique Ecology Well ID Tag No. ALL322 0 Construction/Decommission("x"in circle) t Construction Water Right Permit No.EXEMPT WELL +'' Decommission ORIGINAL INSTALLATION NoticeC Property Owner Name GARY WILSON O ( .. 7`'-7'7Lo of Intent Number Well Street Address 780 E.ISLAND LAKE DRIVE C PROPOSED USE: m Domestic 0 Industrial ❑ Municipal City SHELTON County MASON O ❑DeWater 0 Irrigation ❑Test Well ❑Othertrj EwM Location NE1/4-1/4 SE 1/4 Sec I Twn 201,R 4W or wc.„ co TYPE OF WORK: Owner's number of well(if more than one) W 0°A° E m New well 0 Reconditioned Method:❑Dug El Bored El Driven LatlLong(s,t,r Lat Deg Lat Min/Sec ❑Deepened 0 Cable (Rotary 0 Jetted it2 DIMENSIONS: Diameter of well 6 inches,drilled 80 ft. Still REQUIRED) Long Deg Long Min/See Depth of completed well 80 ft. CONSTRUCTION DETAILS Tax Parcel No. 320065004002 S Casing lZ]Welded 6 " Diam.from +2 ft to 80 ft ✓ Installed: ®Liner installed " Diam from ft.to it CONSTRUCTION OR DECOMMISSION PROCEDURE L Threaded Diam,from ft.10 —fl 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 '0 Type of perforator used information. (USE ADDITIONAL SHEETS IF NECESSARY.) asSIZE of perfs in.by in.and no.of perfs from ft.to ft. MATERIAL FROM TO , Screens: El yes mNo ❑K-Pee Location DARK BROWN SILTY GRAVEL 0 15 �R.r Manufacturer's Name BROWN SILT BOUND SAND,GRAVEL 15 41 0 Type Model No. LOOSE GRAVEL AND WATER 41 58 Diam. Slot size from ft.to ft.R Diam. Slot size from ft.to ft. GRAVEL,SOME SAND AND WATER 58 KO Gravel/Filter packed:0 Yes m No 0 Size of gravel/sand Materials placed from ft.to ft. 'a"s Surface Seal:©Yes ❑No To what depth?20 ft. nsMaterial used in seal BENTONITE CHIPS f-, Did any strata contain unusable water? ❑Yes m No R Type of water? Depth of strata Method of sealing strata off I PUMP: Manufacturer's Name O Type. H P. Z WATER LEVELS: Land-surface elevation above mean sea level ft. (I) Static level 36 ft.below top of well Date 11/16/05 OArtesian pressure lbs.per square inch Date ID Artesian water is controlled by (cap,valve,etc.) ., >4 WELL TESTS: Drawdown is amount water level is lowered below static level ; O Was a pump test made?El Yes NomO If yes,by whom? O's '� 0 I Yield: gal./min.with ft.drawdown after hrs. U Yield:__ gal./min.with ft.drawdown after hrs. l LU Yield: gal/mio.with ft.drawdown after hrs. -� H-- Recovery data(Nine taken as zero when pump turned op(water level measured from well - i O top to water level) I W Time Water Level Time Water Level Time Water Level - '•. C — - 10 'E i'. IID Date of test — S.11 Bailer test gal/min.with ft.drawdown after hrs. - -' QAirtest 26 gal./min.with stem set at 70 ft.for I hrs R Artesian flow g.p.m. Date - Temperature of water Was a chemical analysis made? ❑Yes El No 1 I/16lOS CI Start Date 11/16/05 Completed Date 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 true to my best knowledge and belief. o Driller 0 Engineer 0 Trainee Name(Fri ED NELSON Drilling Company ARCADIA DRILLING INC. Driller/Engineer/Trainee Signature C' Address PO BOX 1790 City,State,Zip SHELTON WA 98584 Driller or trainee License No. 1886 Contractor's If TRAINEE, Driller's Licensed No. Registration No. ARCADD1098K1 Date 11/17/05 Driller's Signature Ecology is an Equal Opportunity Employer. ECYOSO-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: 6/24/25 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 /5/Z„ 30 Min 20 43.8 �2/ 40 Min 20 43.8 b35 Min 20 43.8 ' 6 2025 45 Min 20 43.8 RFC /1/ 0 Total Gallons Pumped: 900 Gallons v anguara Laboratory 2635 Parkinont Lane SW,Suite A Olympia WA 98502 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 04/29/2025 c oast MASON Monty Day Year Type of Water System(check only one box) ❑Group A ❑Group B 0 Other Group A and Group 8 Systems-Provide from Water Facilities Inventory(WFI): System Name: TODD FAGUE n 40 a 11 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) anetatarcadiadnlling.com AND iennQarcadiadnlling.corn SAMPLE INFORMATION Sample collected by(name):MAX Specific location where sample collected: Special instructions or comment: 782 E Island Lk Dr, Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.0 Routine Distribution Sample(AfP) 2.0 Repeat Sample(AIP) 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: Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) S I I ❑E.cot ❑Fecal Feered Yes_No_ ._ 5.®Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifomi Present and Ill Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform /100ml. E.coli /100m1. Fecal Coliform /100m1. HPC /1 ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Date/rime R eived Lab Reference Number cy\9)0a_ \CO v3iC)01-t3t; \C\ Receipt Temp C•: Method Code. S M 922 3 B (.0.0 Date Reported to DOH Lab Use Only DOH Lab-Sample# 285- 43019 DOH Forth#33t-3191dr«ne OW7).1 leo need ens oDhaom n an alternam tm, at to 5250127(rooRTY cal ri1) 2227612 MASON CO WA 07/07/2025 11.49 AM NOTCE GuuONKL I Nry„„it21 1488 Rliec Fee S304 `5k 0 Pages 2IIII'' Renew To 'I�III�III�II II�IIII II� I II�III�It III IIIp�I�llIIII'I�Iill II II IIII NII P. c), . —fi ✓U 4� 40 dCFi82025 /FO Grantor(s):(I) 7?) D L. t tt)F.. ,(2) Al- Grantec(a):(1)PUBLIC (c7 1 2O R Legal Description Description(1) Pu I OF- 7 -39 (Abb►eviarndfarsr:i.e.lot block.pia:orsxtkm (wink'''.range) Assessor's Tax Parcel:(I) & - L/CO ?- 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 Anessors Tax Parcel(I)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) %fit.'. Co- C" Z Tax Parcel:(Connection 2) �2exXn E o The system owner is responsible for keeping this system in compliance. The name of the water system is: (2/G Q.tr7 t�l3AfilG�2 � This system is designed to provide for two service connections.Planning taxi 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 oat)been granted one or more waivers from specific provisions of the regulations. Dated on this a \ day of M oky ,20 a 5 Signature of Grantor(s): (1) / l 41ULC ,(2) r 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 onon _this day of M. ,20,2.5 , x C30 l�ea. ly appeared before me,who is known to be signer of the above inshvment,?d acknowledged that they signed it. GIVEN under my hand and official seal the day and year last above written. L�,n SVsQr RE.N EF �''• Notary Public and for the State of Washington, ��.��p,res resi a1 f� `oF NpTA R Y `� _ My commission expires: ‘ CO" a c� T.;N �, PUBLIC .� z i ',•'9J.' !ssion M �� , ''�O WASH\,,,,,` Page 2 of 2 2227612 Page 2 of 2 07/07/2025 11:49:32 AM Mason County, WA IIIII\ • N /5°22, E / L7 13^ 106.54, ./ yr) 10105, (. I di " ti • 1 I 1 I 1 I i ; r %U N n m r \ ' i W A o o � x � , xZ � m Qcp 6w •• -4 A C D cD Z o CD 1 SI -4 ri ' w D o' Z cfl (A Z in a cr) p v..Z O r Cs — -, c. O D �� Vco o Cll A V3 crn 4O C7� — Z coo ! oo -1' nD N WN Z Q o cD aZyi cr n u r f -.. m ( A - 0CT a I �-' A o m I N W O 4' en - ON O N (ID N • O) N O 1 • 1ii . j I i ' • + I ! I\ 1 ! gA Z SIco ! a co I. • Mj UR N 7S z2'15 AkfNG c.) 1 1 �l 15 22/5, , 180.00, N 80.00. / I/ m \ oo i4d1 / • 11164LINE , w 310 6\4 1 1U-` 71iNE • r5 6086, \ r , 2 73' ���i� N 13 L WgCC 99.25. iZoI • CO O 7 A z o o L 1 ISLAND Rri ORf�49'6z y� ,,J . . \ rn m m c Z OLD LINE � �� �0-1- E _ _ cn '�y < W KD N1 a1 , .---7 �' z c� O 49.52. \ , � ft. � � D C , • L6 �►n r -n � n m Z `� ail v (A O D 0 { . < > m 4) a n 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 \N 0.94 Acres \-' o 'o- n 0S h \ ,goo 6905% ��\5�\NG� DRAIN FIELD 424.31' i"a 5o E 158.4' N 88°51'43"E 1 I 38014 SqFt ` 0.87 Acres ♦ • • N 88°52'53" E _ _ . . . . . . S - . . . . . . . . . . . . . . . . — 322.63, ......................................... MON° ii-tiksf °vWasii RO r a l o N� NOTE:THIS IS NOT A SURVEY ©� z FOR ILUSTRATIVE `� PURPOSES ONLY �°A 4 44645wo S0 �ss�oC!STY, w '"L LAND 0 50' JOB:2025-024 Mill 111.01 BASE-SSSURVEYNAME IIIMII MI INDEX:NE1/4 SE 1/4 AND SE114 SE1/4 AT FULL SCALE,IF NOT ONE INCH SEC. 01,TAN,R4W,W.M. SCALE ACCORDINGLY MASON COUNTY STATE OF WASHINGTON Traverse PC J. in WI a w w JQ "' �- g wa r a a i I • re ui ii di re 0.1 as es i §° Q J _j Q r 'I i & et .. cc lc OQ } O LA iiii I 0 ee . ���.,6� II _... G \,� s 0�'z a JJ X ?.- %ct ,J,W • • % / r 8 , cn V *lcn7 \ OCT 1 0 200 W J vJ V C8 z z w 0 �O i Z p J J W -pi Q 6 O a a0 W <1<i<