HomeMy WebLinkAboutWEL2025-00018 - WEL Application, Design, Letter - 7/7/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670, EXT 400
J BELFAIR:360-275-4467, EXT 400
Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
RETALLICK, JACK and EVANS, ERIN
3320 SE BLOOMFIELD ROAD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00018
3320 SE Bloomfield Rd
319154100000
The 2-party water system, Retallick/Evans Shared Well (319154100000/319154100000), 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
.(? (7a2S
t
"-\ MASON COUNTY Date Received- `(/�
= .1 I. COMMUNITY SERVICES Amou l Received R2ceived By
S6G , �
Building,Planning,far lrvirmental Health,Community Health
415 N.6th Street,(Bldg 8)-Shelton,WA 98584 W E L 7a?5"--060I
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
Jahnee Dragoo 360-912-9507
MAILING ADDRESS-STREET,CITY,STATE,ZIP
607 SE Eaton Blvd Battle Ground, WA 98604 4/4 `2
SITE ADDRESS-STREET,CITY,STATE,ZIP
3320 SE Bloomfield Rd, Shelton, WA 98584 Ric, 1Q?f
PRIMARY PARCEL NUMBER(WELL SITE) 1L
319154100000 FO
SECONDARY PARCEL NUMBER(IF APPLICABLE)
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
❑New la Existing la Well 0 Spring 176598 SF N/A
PROPOSED WATER SYSTEM NAME(REQUIRED)
Retallick/Evans Shared Well
PROJECT DESCRPTION
Existing Well to share connection to existing home with proposed Detached ADU.
DIRECTIONS TO SITE/CONDITIONS
Turn left onto WA-108 E/SE Old Olympic Hwy. Continue to follow SE Old Olympic Hwy for 0.5 mi.Turn left
onto SE Kamilche Point Rd, follwo for 2.8 mi. Turn right onto SE Bloomfield Rd, Destination will be on the left
Site Plan: (may also be attached)
(property boundaries.structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements etc. .)
Submittals Checklist: (these additional items will be required for approval)
2 Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
0 Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
0 Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
2 Septic Records (additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
Staff Use Only - ------ - ----------- ---------------
a
Review Step 1: Well Site Inspection:
; Go- 10 l3
,IS YES 00 NA -"W"►{- KM L{Z
it ":t ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ T ❑ 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?
pl ::: ❑ Satisfactory well cap? Fte��I Culd�ic. WWWO7OS% p pe ' Celd tA rrlt
tlit- ['] ❑ ❑ Well cap screened and vented? ,1
❑ The well casing extends ( above level ground/concrete slab? (circle one)
r ❑ ❑ Evidence of a surface seal? Lat: 47-. t33 18
O l ❑ Adequate surface seal? Lon: -1Z3.0/s Y i
❑ Variance necessary for well site approval? Tag: REGPlf 6
dv
Comments: 641r, G10� 3/2 Y/1'Zr
YU( 7f: Tiro �'rQw a oaf i `&wette d tf4+h Fly ' 1 Col 1�
�, mat(e
Pass ] Fail Inspector 0_,.
Date 4 l IRO Zf
7 RtAitialt l3/i s . fie( anrwnce5 of Te9-1o04 #atv) veil,
Review Step 2: Two-Party Review:
YES NO NA4 n 1715(0,
❑ ❑ Water well report(well log)with a concurrent capacity test?Arceit 'Of.(It�f or) g Oh
❑ ❑ Nonconcurrent/separate capacity test? J p d 60001 9()
Capacity test information: Date Sr(`l�Za7S Driller Ike h Vt'+,r PDMp s l F'(* 1/104,
GPM 5 Duration (minutes) ZZS TotalGal '/ ZS
[g ❑ ❑ Satisfactory bacteriological analysis? Date of test Z ( 2 CI l/ZG Zr
y] ❑ ❑ Signed, notarized, and recorded notice to future property owners? AFN 2 12_1 J 811,4,00
An ❑ ❑ The system appears adequate to serve two connections based on the information provided?
Comments: 9804' ✓o ks,,
O/2Ol5: fl41 � l` ell. Sofa t( Ike(( Sadfa�f co
G���,�� ��o .
7:1-Approved ❑ Denied Reviewer Date 7/7/?02:54,04,41Fy
. r4`yF41rti 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", 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
'""-. ..., .. .. -- .. ....-- .. ..._ ._ . yam.,
r
WATER WELL REPORT
Start Card No. W092225
Unique Well I.D. # ACQ3S6
STATE Of WASHINGTON Water Right Permit No.
4.; STATE
1Q1 9aSO4-
Address S! 391 DARMAN ROAD Q (1) OWNER: Name l--CO ---i>�. PIGGY =,_�..____
-- - 8! 1/4 3I! 1/4 Sec 15 T 19 N., R 3
a/ (2) LOCATION OFDR WELL: County IASON nes
{2a) STREET ADDRESS of WELL (or nearest address) 3320 ILOOIOI1L ROAD, Ste'
CD
U - _- (10) WELL LOG
(3) PROPOSED USE: DOMESTIC
}y (4) TYPE OF WORK: Formation: Describe by color, character, size of material
Ownem'sr Nthanr of well and structure, and show thickness of aquifers and the kind
(et ode ROTARY
one) and nature of the material in each stratum pen
etrated, with
If
sMIN p (fit ` at least one entry for each change in formation.
C: Diameter of well 6 inches FROM TO
(5) DIMENSIONS:rd completed well 64 ft. MATERIAL 0 S
C Drilled 63 ft. Depth of RIAMN Sim Amp PR01 GRAM 0 10
O ._/ sum mom CLAY 10 36
(6) CONSTRUCTION DETAILS: °!_y' 36 65
E • Dia. from •1 t. to 60,5 f . COURSE ND OSAVLI. i WATER R Casing installed: 6 •
Dia. from ft. to ft. 63
mum CA8TDiG • Dia. from ft. to ft. GRAY CLAY
L
W Perforations: NO
CType of perforator used in in.
CD SIZE of perforations ft.
.Cperforations from ft. to
,N ft. to ft.
a. perforations from perforations from ft to ft.
CScreens: YID mom
VSManufacturer's Name Model No.
Type SI.OTTRD ,
2 Diem. 6 slot size .030 from 64.6 ft. too 56 ft. 4E1.7 ,
slot size from 7T
05 Diam.
Size of gravel L. 0
co Gravel packed: MO ft. to ft.
Gravel placed from - —'
Zi Surface seal: Y!8
To what depth? 20 ft.
Material used in seal ERIFIVMIT!RS -
Did any strata contain unusable wat7e�f strata ft.
L Type of water? Depth . '�
L Method of sealing strata off
Va
R =
7j (7) PUMP: Manufacturer's Nye H.P.
'(9) WATER LEVELS: r•
Z Land-surface elevation ft.
above mean sea level ...
Static level
43 ft. below top of well Date 09/15/97 I
01
C) Artesian per souare inch Date Artesian PressureCompleted 09/1S/97
13 Artesian water controlled by Work started 09/iS/97
`__ _ELL is amount water level is lowered below NELLI CONSTRUCTOR
constructed CERTIFICATION responsibility for con-
rn
C) WELL TESTS: Dra l
staticmd level. whom? struction of this well, and its compliance with al
l
0 Was a pump test merme with If yes, by hrs. Washington well construction standards. materials used
C� Yield: gal./min ft. drawdown afterand the information reported above are true to my
W knowledge and belief.
0 Recovery data mammaDRILLING
or print)
++ Time Water Level Time Water Level Time Water Level NAME (Person, firm, or corpora ion) (Type
C
CO (Person,
SR 170
License No. 2057
L Date of test / / ft. drawdown after bra. [SIGNED]
Q Bailer test gal/min.
Air test 6 gal/min. w/ stem set at 60 ft. for
hrs. Contractor' Date 09/15/97
Q� Registrationo ' No. aACl�DDIO9aR1
Q Artesian flow g.p.m. Was a chemical analysis made? MO
Temperature of water
.0
I—
e
i� Cont.#MTNV1VP867MA
Mountain View
Pumps & Filtration, Inc.
32519 Mountain Highway E. Eatonville, WA 98328
(253)847-5259 Fax (253) 846-3761 Email: infoAmountainviewpumps.com
2 HR Stabilized Pump Test With Drawdown & Recovery JON
RFc, �22025
DATE: 05/14/2025 F/1/4.0
SYSTEM NAME: Retallick Water System
ADDRESS: 3320 SE Bloomfield Rd, Shelton WA 98584
Depth of Well: 62-1/2' Static: 45' Pump Set Depth: 57'
1 TIME ELAPSED STATIC DRAWDOWN PUMPING REMARKS
PUMPING LEVEL FROM STATIC RATE
TIME (min) LEVEL (gpm)
10:15 0 45' 0' 5
10:15 30sec 47' 2' 5
10:15 45sec 49' 4' 5
10:16 l 50' 5' 5
10:16 1 min 30sec 51' 6' 5
10:16 _ lmin 45sec 52' 7' 5
10:17 2 53' 8' 5
10:17 2min 30scc 54' 9' 3 Reduced flow at intake
10:18 3 56' 1 1' 4
10:19 4 56' 11' 5 At Intake
10:20 5 57' 12' 5 "
10:25 10 57' 12' 5 "
10:30 15 57' 12' 5
10:45 30 57' 12' 5 `'
11:00 45 57' 12' 5
11:15 60 57 12' 5 "
11:30 75 57' 12' 5 "
11:45 90 57' 12' 5 "
12:00 105 57' 12' 5 "
12:15 120 57' 12' 5 Stabilize(ti,Intake
12:30 135 57' 12' 5 "
1:00 165 57' 12' 5 "
1:15 180 57' 12' 5 "
1:30 195 57' 12' 5 "
2:00 210 57' 12' 5 "
2:15 225 57' 12' 5 44
RECOVERY: 15min 32sec to Recover
TIME #MIN DEPTH TIME #MIN DEPTH TIME #MIN DEPTH
2:15 0 57'
2:15 lOsec 56'
2:15 20sec 55'
2:16 1 54'
2:17 2 53'
2:18 3 52'
2:19 4 51'
2:20 5 50'
2:21 6 49'
2:25 10 48'
2:30 15min 32sec 45'
Suggestion: Technicians suggest adding a 1550ga1 storage tank to the system. Estimate to
follow.
Signature,-
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506 -
�, 360 867-2631
THURSTON COUNTY .
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
Z _' 2 l 0 : 4! PM i�,\Gi S u,.'1
'Muth Day Year
Type of Water System(check only one box) yl.Private Household
0 Group A 0 Group B 0 Other_
Group A and Group B Systems-Provide from Water Facilities Inventory WI):
ID# A C U, S c .t.
System Name:
thkndi.uu/1
Contact Person: it t,^ ,Cc (4 el .,
Day Phone:(l. t) Q) 1,4' 0-c — Cell Phone:( ) V)s` 41+6
E-mail:iC C ,(Q}cA II i(l� yw,I.Cv,�ve.Phone:(Y,01 )S.5 i 52 12
(C resulults to:(P'nt full name,address and code or all address) - tt\O a SA •
if-ttn �{VC1r, 5 / �Z'(14- \ 141l(Itk c'vnc,, I
'VI)-G cL \3lvca' 't-I tc.A R O
S1 l+vn W A `i f.,S l
SAMPLE INFORMATION
Sample collected by(name): .
�CvLen c" JcA ✓1r
Specific location or address where sample collected: Special instructions or comments:
a))) lQ <F \3i0,;.Mc,=I.c Q-)
Type of Sample(must check only one box of#1 through#4 listed below)
1.O_Routine Distribution Sample 2.Repeat Sample(after unsat routine)
Chlorinated:Yes No X . ❑Distribution System
Chlorine Residual!Total__Free__ Chlorinated:Yes_ No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli-GWR(AIP)
❑Fecal-s.rrx.R.WWI sprigs(numerator.) Unsatisfactory routine lab number
Filtered:Yes-- _No_._ _ - _ .._ —_ __
❑Assessment Monitoring(ANP) Unsatisfactory routine collect date:
❑Other / /
S
4.1Z1Sample Collected for Information Only
Investigative 1--. Construction I Repairs_ Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and M tisfactory
0 E.coli present 0 E.coli absent
t^ .liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC 0_--
Bacterial Density Results:Total Coliform_____1100m1. E.coli /100rrt.
Fecal Coliform /100m1 Enterococci_ /100 ml.
Method Code: SM 9223B OSM 9222D Date and Time Received: �.�
SM 9215B 0 Enterolert0 'Z-Zy4-7-5' L4tit
Date and Time Analyzed: Z- 2,4"2-5 Date Reported?-15 >"K*
Sanp'a Number(DOH number plus Eve dgas) Lab Use Only.
(] 8 0 ' .
DOH Form#331319(2Nsed 11/23) Ole .5 rl 9 7
2227388 MASON CO WA
06/30/2025 01.59 PM NOTCE
WOLF INDUSTRIES 1$211297 Roc Fee $304 50 Pages 2
1II II I III i IIIId1IIIIII IU IID III'+.!liii III1111 II IIi I IIIII IIII
Return To �O ,
% �0��Wolf Industries 0
607 SE Eaton Blvd Q��Ok\
Battle Ground, WA 98604
164
Grantor(s): (1) Jack Retailick , (2) Erin Evans
Grantee(s): (1) PUBLIC
Legal Description (1) NE SE * S 45/71, R 3W, T 19N ,Sec: 15
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 1 9 1 5 - 4 1 - 0 0 0 0 0
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 1) 3 1 9 1 5 - 4 1 _ 0 0 0 0 0
Tax Parcel: (Connection 2) 3 1 9 1 5 _ 4 1 - 0 0 0 0 0
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Retallick/Evans Shared Well
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, !_ -S day of re L):-., r. , 20 2c
Signature of Grantor(s): c
(1) , (2)
Page 1 of 2
State of Washington )
County of r ur5..fbiA@ )
1, the undersigned, a Notary Pub' ' and for the above named County and State, do hereby
certify at on th's day of , 20 25 ,
1 {G- perso ally 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 e r I st abo written.
CHARLENA LANE
NOTARY PUBLIC 11210123M Nota uh' n ands fQr the(,State f Washington,
STATE OF WASHINGTON residing at1 U
COMMISSION EXPIRES ; My commission expires:
MARCH 31, 2023 •
Page 2 of 2
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/ $\- MASON COUNTY ENV1RONYENTAL HEALTH +: ., � _,t,
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EXN
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BE CHARGED AT TIME OF IN:-.TALLATGON
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