HomeMy WebLinkAboutWEL2025-00033 - WEL Application, Design, Letter - 7/7/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
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
AVERY, JAMES & DIANE
70 SE SELLS DR
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00033
70 SE Sells Dr
319024390022
The 2-party water system, Avery Trust Water System (319024390022/319024390022), 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
IgriT. MASON COUNTY Date Received: CO _ 31 c� .�Amount Received Received B
.�_ 1 COMMUNITY SERVICES AmoWading,\..
AdWading,WamY)g,Envirminentel Health,Community Health SIiJ
415N.611'Street,(Bldg8)—Shelton,WA98584 WEL aoaJ . 00 c5 3 3
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
:APPLICANT PHONE:
•
Ta►Nl42 S e D r<c )- ect. -3 - 4 7O__ ).61.70
NAILING ADDRESS-STRF:F'.CI'IY.STATE,ZIP \ �j (�
7c) S C. c2Lis-Dr. ShEL-fou� tk•1�I.� .. 1 5Z�
SITS:ADDRESS-STREET,crr',SCATE,LI' ) /
�� /
PRIMARY PARCEL NUMBER(WELL SITE)
i9D 3c?D9-Z UT 2 aF S P .4-3e07--AF1?DZn it (eDZIge PT N V r/25
- SECONDARY PARCEL NUMBER(SAME:AS PRIMARY IF LOCATED ON SAME:PARCEL) /
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WATER SOL(RCF. � // SOURCE"IYPE PARCEL I LOT SIZE(min I acre) PARCEL 2 LOT SIZEI min I;Icre)
!'New 'b Existing V Well b. Spring 3111_cYe _:,
PROPOSED WATER SYSTEM NAME IRE:QUIRF.D).
Aim T(17 t Wutei S S: eU k
PROJECT DESCRIP LION(e.g..deachedAl)1-.nee-single-family residence.existing conneclion.ee .)
A CIC Yl Cl l 149 s4?..,i,(X:re vz.-)t Al) 4 -f o oU f p te-
-6)utS vwea►� a\it cat?; ; ',tia I knoe v
DIRLCI IONS TO SITE/C'ONDIT IONS/GAT ('ODE KE ' ('ATION/ETC.
FDc1�' ;le = o l0 f v>Iti iti(_�1 }- t,a trJ Se(l 5r
1-Of vt .�� vA 5((' (A tc? CiftU e u)rA c) k_ Ravi- 7ut.. S-Qi IS
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.)
CO
61
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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
Wotice 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 he 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
❑ Eti ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
❑ [ ❑ 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)
t6 ❑ ❑ Does the ground slope away from the water source site?
X ❑ ❑ Satisfactory well cap?
F ❑ ❑ Well cap screened and vented? y
❑ The well casing extends l& above level u /concrete slab?(circle one)
,k ❑ ❑ Evidence of a surface seal? Lat: 47. (5cf7
p ❑ ❑ Adequate surface seal? Lon:—173.0-KA
❑ X ❑ Variance necessary for well site approval? Tag: (T(J
Comments:
Pass El Fail Inspector Date ‘l L 7/Zd?r•
Review Step 2: Two-Party Review:
YES NO NA
jt ❑ Water well report(well log)with a concurrent capacity test? OWN O illtYly on /3l��T�' Ivor,
❑ ❑ Nonconcurrent/separate capacity test? /
Capacity test information: Date 6ati ZO 75 Driller ita(46l Pr?II(ill
GPM 17 Duration(minutes) 60 Total Gal T
iff ❑ ❑ Satisfactory bacteriological analysis? Date of test 6( /( ?o 75
j ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN ZZ Z 7 cI 3
X ❑ ❑ The system appears adequate to serve two connections based on the information provided? qAp
Comments: dri®
Approved ❑ Denied Reviewerfk-*------"-- Date ?I & $ "2O2
4.,,,
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,dpress4,AZ yFq
or implied of the future success or failure of this system. Well site approval does not constitute water system approval l of
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
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WATER WELL
REPORT Start Card No.
045351
L STATE OF WASHINGTCa _Water R Permit ho.
L __ai=_2226=■Z_= _._ _ = �
Q (1) OWNER: Name LINKS, DON Address SE 3850 LYNCH RD SHELTON, W , 98584-
■■=■■=3xs===s■= za=zAmwom zss■■zL2■■■■s ss■■■a■■■�22=32=a=
y=cs22as2z2s:zr=:z=aa■sss:s:t = = L
- SE 1/4 NE 1/4 Sec 1 T 19 M., R 3 Wll
(2) LOCATION OF WELL: County MASON , ��,,�� �_�fly 9 _Y
Ce (2a) STREET ADDRESS OF WELL (or nearest address) SE 3850 LYNCH RD sf � fw�s■ _ :a■: ■ _________
__ -2sa
s�=■■■■sz:■:22:��:■.■:___■_=-�3=-= (10) WELL LOG
4) (3) PROPOSED USE: DOMESTIC
4■_TYPE OF WORK: =sss====asT.M= ':� Formation: Describe by color, character, size of eateriel
(4) TYPE OF WORK: Owner's
more Number ofe well and structure, and show thickness of aquifers and the kind
y Method: OTAn one) penetrated, with
ROTARY and nature of the material in
Inrformat .
NEW WELLet least one entry
2ca■Sz32■■i:■izz■s2:czaa
0 (5) DIMENSIONS: Diameter of well 6 inches FROM TO
ODepth of completed well 108 ft. MATERIAL F 16
Drilled 108 ft. ■2■222■■2■=■■2122221u2ta CLAY I SAND 06 22
=222z■szs■sz■:zcsy2zss.:a■2a■2cz�z�cs2 CLAY & GRAVEL
O (6) CONSTRUCTION DETAILS: 16 120
03 Casing installed' 6 " Dia. from
from+1 ft. to 108 ft. BLUE CLAY 2200 100
WELDED D ft. to ft. COURSE GRAVEL & WATER
E " Dia. from ft. to ft.
te- Perforations: NO
- Type of perforator used
0) in. by in.SIZE of perforations ft. to ft.
perforations from
perforations from ft. to ft.
s-O perforations from ft. to ft.
Screens: NO
Manufacturer's Name
03
Typo Model No. ft.
Di . slot size from ft. to
,e,r franc ft. to ft.
DiemCI3 . slot size
in
Gravel packed: NO Size of gravel
s
Gravel placed from ft. to ft.
a'' Surface seal: YES To what depth? 20 ft.
4-0 Material used in seal BENTONITE
03 Did any scrota contain unusable Dth?of strata ft.
Type of water?
L Method of sealing strata off
♦y =s2=z=ss=====ms=ssz••-.....==..===s======ssssms=z■=sYzzss■ss■=sz
(7) PUMP: Manufacturer's Name H.P.
0
x .a=c2=
(8) WATER LEVELS: Land-surface elevation ft.
Z above mean sea level ...
In Static level 68 ft. below top of well Date 09/03/91
OArtesian Pressure lbs. per square inch Date
'a
Artesian water controlled by Work started 09/03/91 Completed 09/03/91
_�_->��=a:czzz=■==sa=s_=saes=zszzs=■aa■c=zsaas��z
=sass=:cam==:aasx z==-sscnzsz=zs =zs=■caz=zaazszaaas?
a7 (9) WELL TESTS: Drawdown is amount water level is lowered below WELL constructedcoS CERTIFICATION:
and/or ERTI FICATaccept'responaibil{tY for con
O static level. hom? struction of this well, and its conplianee With all
O Was a pump testa made? withNO If yes, byd wwdow
U Yield: gal./min ft. drawdown after hrs. Wandhthetinfowell
rmation reported aboonstruction ve trueMaterials
best
4- knowledge and belief.
O Recovery data
++ Time Water Levet Time Water Level Time Water Level NAME AR�on, or D I LLINGiNC.
corporation) (Type or print)
C
d
ADDRESS SE 70 R PARK RD
i Date of test / / L{canoe No. 0950
04 Bailer test;, gat/min. ft. drawdown after hrs. (SIGNED) -
al stem set at 88 ft. for 1 hrs.
al Air test flow g /min. w/ Date Contractor's Date 09/09/91
Temperat'r g.p.m. Registration No. ARCADD•147K1
4
, Temperature of water Was a chemical analysis made? NO zssa=2s_====s2===z■sss 22=2Z c2s=2222 a=22222===---'---
I—
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: t,t.t.S / ' • - 't{
Well Tag #: 40 -
Site Address: 70 Sc S.c/f S \J✓ Depth: /6 8' Fi--
Static:(oS'-.
Date of Test: (�//z/2.�
Pump Set: %S-
TIME GPM LEVEL RECOVERY
1 Min !p (PG. O TIME LEVEL
2 Min (0 4l0_ 2— 1 Min (, i 7
3Min lb , 0, Z, 2 M i n (e $ , 3
4 Min 1 b (,G,Z 3 Min id 7. S-
5 Min 10 (24-2- 4 Min (4. I
6 Min 1-1 (c 4(, `I 5 Min (rG, i
7 Min li (09,,7 6 Min ( .S, 7/
8 Min (7 G Q,4 7 Min
9 Min 1i 61, 1, 8 Min
10 Min (7 (p 5 L 9 Min
15Min )? tf, L 10 Min
20 Min l'i (oq, L 11 Min
25 Min n 1.4, l. 12 Min
30 Min 1--1 (pQ. L 13 Min
35 Min () 6,9-1, 14 Min
I 40 Min [`( (a f, •
( 15 Min
45 Min /7 �Q (n 16 Min
50 Min )1 6f, (, 17Min
55Min 17 4,f_ G 18Min
1 Hr t 7 G. (, 19 Min
1 Hr 10 Min 20 Min
1 Hr 20 Min 21 Min
1 Hr 30 Min 22 Min
1 Hr 40 Min 23 Min
1 Hr 50 Min 24 Min
2 Hr 25 Min
2 Hr 10 Min 26 Min
2 Hr 20 min 27 Min
2 Hr 30 Min 28 Min
2 Hr 40 Min 29 Min
2 Hr 50 Min 30 Min
3 Hr
3 Hr 10 Min
3 hr 20 Min
3 hr 30 Min
3 Hr 40 Min /j
3Hr50min 9 �� A4 / 9e, Ahc /� v
4 Hr /
•
Vanguard Laboratory
2635 Parkmont Lane SW
Olympia,WA 98502
360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Collected by:
Jim Avery Matrix Drinking Water
360-490-2970 Laboratory ID: V250602-8
Sampling Address: Date Sampled: 6/2/25 15:30
70 SE Sells Dr Date Received: 6/2/25 16:08
Shelton,WA 98584 Date Reported: 6/3/2025
Sample ID: 70 SE Sells Dr
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.coil by SM 9223B(IDEXX) Batch ID:V250602-8 Analyst:AF
Coliform,Total Negative 1 1 MPN/100 mL 1 6/2/25 17:24
E.coli Negative 1 1 MPN/100 mL 1 6225 17:24
Notes:
MPN:Most Probable Number
ppm:parts per million
nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 06/03/2025
n/a:not applicable
SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 06/03/2025
DF:Dilution Factor
17025:2017
MCL:Maximum Contaminant Level i �r
.o�r,
Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent
with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results.
2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com
www.vanguardlaboratory.com
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c..�, &O 5 .000 3
A 2227513 MASON CO WA
07/02/2025 02:37 PM NOTCE
AVERY R21/406 Rec Fee $304 50 III1h1 Pages 2
IIII11 III III IIII�I 111111 IIII IIIN IMII 1111111 III 1i 11111 IIN 111
Return 10
.a,1v1e5 {�. l� e gcit NMCMII V�
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/.A t' I-1Ced to I . 61C` `- "" 0 2 2025
Jut 0 3 2n
BY: RECEIVED
Grantor(s): (1) 12• 1.;Je,e(,' .(2) t)I�11� C - e 4_1
Grantee(s): (I)PUBLIC
Legal Description (1) LC 1' 2 C)i; S e i ' C09 Ai:0 IRO Z G eic. PTA) I . 5 C
(.4bhreviatedform: i.e. lot, block plat or section.township.range)
Assessor's Tax Parcel:(1) 14 '3 1 ct V 243 et O 0 2_ Z--.
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(l)and Assessors 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) 1 CI 0 Z 43 c10 022
Tax Parcel:(Connection 2)_
The system owner is responsible for keeping this system in compliance.
The name of the water system is: (1V Ir Ry TRUST W Af iZ 3y5"f'E N\.
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 day of . 20
Signature of Grantor(s):r(
e4.e. .(2)
Page 1 of 2
t
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 L n d day of i.t 1 . , 20 Z S
JGr nKj Gird 1)1G1tNe— 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.
¶tr-eN 1\J
Yo VFq �% Notary Public in and fo the State of Washington.
.r:No �oj• ' residing at 51"s.
� p[ARY _ My commission expires: Gf-ZI" Zn
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Page 2 of 2
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APPROVED
/ MAY 2.1 2025
C lit) MASON CO;1NrY ENViliONMENTA HEW
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