HomeMy WebLinkAboutWEL2025-00034 - WEL Application, Design, Letter - 7/14/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
M. , SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
FEY ET AL LORI A
71 W RUSTIC LN
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2025-00034
71 W Rustic Ln
420224490036
The 2-party water system, RUSTIC WATER WAY (420224490036/420224490036), 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
07s, MASON COUNTY Date Received: • n - a Da 3
'=1 COMMUNITY SERVICES Amount Received: Received
�,
Bolding,Flaming,Environmental Health Cotrttranity Health mac,
415 N.6'a Street,(Bldg 8)—Shelton,WA 98584 WE L aola 5 _ 0 003q
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT0r: �`'A PHONE
( ✓ ggtl
MAILING ADDRESS-STREET,CITY,STATE,ZIP
SITE 1 1.),S- � OffS - �f�ii 1-6- x- / TAIL, L119 9scs O
,STATE,ZIP
I/ fJ-6b�- /2vckz, l ari.e, ,, -d - i ill'- '7F Sid/
PRIMARY PARCEL NUMBER(WELL SITE)
1/2-O2,2, - Liy -'DO2Ce
SECONDARY PARCEL NUMBERS ME AS PRI ARVLOCATED ON SAME PARCEL)
LiLia CE a c,a . 4
WATER SOURCE SOURCE PARCEL I LOT SIZE(ink I acre) PARCEL 2 LOT SIZE(min I acre)
C New Let<isting [/Well Spring
PRO ED WATER SYSTEM NAME(REQUIRED
IPROJECT DESCRIPTION(e.g.,detached ADU,new single-family residence,existing coon n,etc.)
DIRECTIONS TO SITE/CONDITIONS/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.)
t ` g
t C
t
t V iv
t V b
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Required Submittals Checklist:(additional information located on the first page of this packet)
V Satisfactory bacteriological test from within the last year
42 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)
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
Eltu ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
0 ❑ 0 Are there ro ith'. • 100-foot radius of the water source? 3G
Is the roa. ' . , ounty,or State?(circle one) Distance to the road(s)
❑p ❑ Does the ground slope away from the water source site? / ����
C0414 - El Satisfactory well cap? ^ II 0✓f- of y �/is foe is, etc c fvi► u f `((et'e-
V (X ❑ ElWell cap screened and vented? (. ``
CI The well casing extends if-
above level ground/concrete slab?(circle one)
y ❑ El Evidence of a surface seal? Lat: 4 1-t0 3l1
/In ❑ ❑ Adequate surface seal? Lon: "l2i,A(rS(V
❑ 0 ❑ Variance necessary for well site approval? Tag: ACE7603
Comments: , *ow kilt/5 )kiciestiefelechital rostit l eye 7l8'llo zc
Pass' il Inspector Date p
lig(? 7
Review Step 2: Two-Party Review:
YES NO NAy. `�� /� Q gyp. {�(
❑ M Water well report(well log)with a concurrent capacity test? '4/%'v 4�on I1t(!ft'f f;"" f 'c`c
❑ Nonconcurrent/separate capacity test?
Capacity test information: Date fig!ZO7/ Driller /lll 4 ON"
y
GPM (5 Duration(minutes) 60 Total Gal M0
iel ❑ ❑ Satisfactory bacteriological analysis? Date of test Ono zc
t ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN ti i Z..-7??8
jaT ❑ ❑ The system appears adequate to serve two connections based on the information provided?
Comments:
fiApproved ❑ Denied Reviewer Date RV 70X
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
Swt Card hid/`" 07'7zo a
FlDepartment
rtmett of
Ecology
Copy with WATER WELL REPORT UNIQUE WELL 1.D.AEG- 667
Deperbnent of Eedogy
Second Copy-Owner's Copy STATE OF WASHINGTON
Third Copy-Drlller'a Cony Water Right Permit No.
O (1) OWNER: Name 2-0/ ,i ._(-TO.. {- / -- �-7 s ) J 77-Le_K aA S.14-4,r Ce CL
(2) LOCATION OF WELL: County -, 1/4 1.4 Sec ZZ T. ZO N,A CJW M..
(2a) STREET ADDRESS OF WELL or nearest adtresal 3T ) 17 CZ /" ' 72.4e.. /I L, S.t 7Z)& ci(J t 65 1 '
ty
(3) PROPOSED USE: 0 Domestic Industrial Ci Municipal 0 (1B) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
C Irrigation Test Wei 0 Otter O Formation:Describe by color.charade.,sate of meanie!and structure.and show thi:knees of aquifers
N L OeWater and eta kind and nature of the material in each sinews penetrated,wan at bast one entry for each
Owner's number Of well change of information. - _
'�.+ (4) TYPE OF WORK: Of more than one) PROS To
MATERIAL
O Abandoned C New well A MSMod:Oug❑ Bored[7 r
O Deepened C Rotary❑ Jetted❑ n 1
� Reconditioned C /tQ n/ _ Q�
O _ Inches. `d _. � .135 f o
'� (5) DIMENSIONS: Diameter of well .- /a T
priled//D feet. Depth of completed well / ft. . �t2SN f
E E — - uy go 97
o (6) CONSTRUCTION DETAILS: t'Lt Er wJ / _ ,T jai
= Csslftq Installed: 49 • Dram.horrrf' ft.to /� " 4.41N1 f-t'rL L /p! I 10
Welded Nun.en.from f,.to ... ft (I ,�Tey jt ram( LtiKT"
O LinernerThreaedded�d C — - Diem.from .. _If.to ft /+�
- --- -
>r Perforstkms: Yes❑ f
O Type of perforator used ..-- _...-
SIZE of perforations -. In.by - in.
COCO perforations from ft to h-
f.
perforations from ft b ft.
coperforations from ft.to f. _ - 0 L.
- t,
Mane Manufacturer's
Yes® No❑ 4
SMarwtacarer'a Ns (/f`/ram' t
i+ G Type _ Model No. r -- r
r�i -l-Dion. Slot size , IDA, hom /177 ft.to a ft.
C ✓ Diem. Slot size from It.to ft
A f
L Gravel packed: Yes ❑ No Size of gravel - _ -- _
CZI Gavel placed Irom - ft to Q ft - }
Surface deal: Yes No❑ To what depth? .113 it
0 Material used in seal
Z Did any strata contain unusable water? Yes Cl No$
Type of water? Depth of atrata -
(1) Method of sealing strata oft . —
O
(7) PUMP: Manufacturer's Name- ._
A TYPm: - _ H.P. - -
cn
O WATER LEVELS: Lam4arran elerason Work Started
19 7-2 9.8 19_
(6) above mean sea level et.
State b el l o.below top o+"°s Date Z -arm WELL CONSTRUCTOR CERTIFICATION:
per square inch Date
L 1 Artesian pressure ,_,. UR.p
Mayan water a controled by I constructed and/or accept responsibility for construction of this well, and its
tit_ (Cw,valve,etc.} --- compliance with all Washington well construction standards.Materials used and
O the information reported above are true to my best knowledge and belief.
+-r (9) WELL TESTS: Drewdown Is amount water level is lowered below static level
CIWas a pump test made? Yes❑ No 0 If yes.by whom? kcjzzi , '
E Yield- gal.,'min.with tt.drawdown after hrs. NAM teem on Con
— " Addrepj& l c ) fi i- L t.d 20, /�'14,4
•
p
a - „ (s /h �-2A- - . License No l
water levet measured from well Igne��`/L e
fy RgCpvery data(flme taken as zero when pump turned ors)( twat oauErt)
0 top to water level)
Time Water Level Time Water Level Time Water Level Contractor's
_ - Ozi Date-7-?7 98 19
(USE ADDITIONAL SHEETS IF NECESSARY)
Date of test
Bailer test Zo gal.rmin.with - Q tt.drawdown after L[J hrs is an Equal Opportunity and Affirmative Acrtfon employer.For
Airiest gal.n/an Ecology with stem set at -- ft for hrs. spe-
cial accommodation needs,contact the Water Resources Program at(206)
Artesian flow . _ g.p.m. Date
407-6600.The TDD number is(206)407-6006.
Temperature of water Was a chemical analysis made? Yes❑ No
Igl
ECr 050-1-20(9r93)''I
Arcadia Drilling Inc.
P.O. Box 1790
Shelton, WA. 98584
Customer: Lori Fey Well Tag#: AEG607
Site Address: 71 W Rustic Ln, Shelton Depth: 110'
Date of Test: 7/8/25 Static: 95.9'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY
1 Min 15 96.9 TIME LEVEL
2 Min 15 96.9 1 Min 95.9
3 Min 15 96.9
4 Min 15 96.9
5 Min 15 96.9
6 Min 15 96.9
7 Min 15 96.9
8 Min _ 15 96.9 /�
9 Min 15 96.9 ✓(/`
10 Min 15 96.9
15 Min 15 96.9 _ 'Q ,1
20 Min 15 96.9 �C-/`„ ��<
25 Min 15 96.9
30 Min 15 96.9
35 Min 15 96.9
40 Min 15 96.9
45 Min 15 96.9
50 Min 15 96.9
55 Min 15 96.9
1 Hr 15 96.9
Total Gallons Pumped: 900 Gallons
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506 '
360 867-2631
- -
THURSION COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected �/J
Moral Day Year D PM
Type of Water System(check only one box) IQ Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WEI):
ID# —System Name:
Contact Person: L.0 QI c(yam Y
Day Phone:( UO) L!Z_(s .�1 SC-J Cell Phone:(306)2 O -zq3C/
E-mail:l�P I.ce Cyr �'CJ(J (TL I i 011(4.(E i one:( )
Send results to:(Print to name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name): tiA
�L y
Specific location or address where sample collected: Special instructions or comments:
JUN 1 6 2015 �e , wA qwc:jc
RECEIVED Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes_ _No ❑Distribution System
Chlorine Residual:Total_ Free Chlorinated:Yes No.
3.Raw Water Source Sample Chlorine Residual:Total Free_
❑E.coli—GWR(AlP)
❑Fecal—Surixe.Gwl.springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / 1
S
4.Eit Sample Collected for Information Only
Investigative X Construction/Repairs . Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent
No liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC • ❑
Bacterial Density Results:Total Coliform_ /100m1. E.coli 1100m1.
• Fecal Coliform _. __.___./100m1 Enterococci _/100 ml.
Method Code: 1SM 9223E OSM 9222D Date and Time Received:
SM 9215E ❑Enterolert® (, ll Q_'2$ V�
Date and Time Analyzed( Yi 1� Date Reported. (, rt.„
Sample Number(DOH number plus five digits) Lab Use Only:
0 8 0 4Cls
DOH Form#331-319(limed 11123) ------ -- C
�yCGSh 24 ' t 5
2227728 MASON CO WA
07/09/2025 01 22 PM NOTCE
FEY, LORI 1211601 Rec Fee 5304 50 Pages 2
1111111111111111111111111111111111111111111011111111111111
Return To
Lot( U
11 w 2usri< <,� D
TvA)I A ct5�c/ JUL 0 .9 2025
By
Grantor(s): (l) kb Q.t i S 1' ,(2)
Grantee(s):(1) PUBLIC 5t c-av - q Lea 5 $7 f
Legal Description (1) Li 1/2 ' %1Z- 1 f N tJ N C t N a N 441
WO
(.thh viated form: i.e..lot, blocA,plat or section, township,range)
Assessor's Tax Parcel: (1)_WO0:9a - 7O3 '
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I(We)the undersigned grantor(s),certify that the water source located on the above-described real estate
under Legal Description(1)and Assessors Tax Parcel(1)situated in Mason County,State of
Washington,has been designated to serve a source of water to the following parcels situated in Mason
County, State of Washington; herein described:
Tax Parcel:(Connection ]) L1 Z o 2 2` yy - O O 3(
Tax Parcel:(Connection 2)
The system owner is responsible for keeping this system in compliance.
The name of the water system is:
This system is designed to provide for two service connections. Planning and design approvals must be
obtained from the department prior to expanding beyond this number of services.
Additionally,a water right,obtained from the Department of Ecology, is required if the water system
exceeds exemption standards.
This system(has/has not)been granted one or more waivers from specific provisions of the regulations.
Dated on this 16 day of Tii,!!Il ,20 v`�S
Signature of antor(s):
(I) 0 _.(2)
Page 1 of 2
State of Washington
County of Mason
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify
that on this I day of 3 IA1r1,Q. ,20 2.5,
Lbyi A Fey personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
Stil.0(11r) g
,,,,``���swA Notary Public in an or the State of Washington,
x• • eion E• .• q residing at$k't,in.CAVY1 �17 "r 1
�i,�
y My commission expires:
� o
:c° p�ARY s
•:<. UB YS ro'
itr•nB 1�el• 0
OFW,_ „,,•
•
Page 2 of 2
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Printed From Mason County DMS
Printed from Mason County DMS