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HomeMy WebLinkAboutWEL2025-00095 - WEL Application, Design, Letter - 9/3/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 a , 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 09/03/2025 BOUDREAU JEFFREY 90 NE PINE CAMP RD BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00095 90 NE Pine Camp Rd 223117600390 The 2-party water system, Private Well (223117600390/223117600390), 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 1m [EcEllwE -_-;\ / `-- \ MASON COU II J U L 2 9 2025 / Received: O — /�/� ' (� COMMUNITY! RVICES + L1, ,�J (;J`/�(/I' exiv�d . ��.�_` �►A`�', Amount Received' R By. Building Planning,Enviranmertal Health, lY nity Health ■ 415 N.6th Street,(Bldg 8)-Shelton,WA 98584 WE L go a5 - 00096 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT Ayy r-,eV BD Li d `e +A. L 7.;06,) a�c0 — ? J ) MAILING STET,CITY,SrATE .2„ At,--, (6_ ' P 77 ex'd *B-Q/ I.rk/C3 , Q?, ', RS ?T,CITY,96 Ai SITE, d)A.A 00/ -ac=./ ';r-, Ihk? i�sa7 PRIMARY PARCEL umBE/R(WELL SITE) 2 SECONDARY a PARCEL NUMBER(SAME 1 PRIMARY IF ,,3 ON SAME PARCEL) WATER SOURCE SOURCE TYPE PARCEL I LOT SUE(mia I ern) PARCEL 2 LOT SIZE(min I acre) New )(Existing Well Spring 5 PROPOSED WATER SYSTEMSAME(REQUIRED). T"11�e Q� LI9EAT PROJEQT DESCRIPTION(e.g.,detached ADU,new sin—gle-filsoily residence,existing cognation,etc.) R Da < /c cdn I) /P n�i/ (-1--e) 1 , c o 1 DIRECTIONS TO SITE/CONDITIONS/GATE CODE/KEY LOCATION/ETC. t3ctp- n-k . A( JO i9Pc1/11/(91) / V55z 6) ‘ii'd ,r 7 --1,. Le pf Qro, c I enr P,i 6(k Cli-,u-f_ b r-Vh 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.) Sese.. Ckk"- *CdikC)/\eCA. Required Submittals Checklist: (additional information located on the first page of this packet) rriiief atisfactory bacteriological test from within the last year ell report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day t i Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office eir 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 I of 2 immommir • • Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ )] 0 Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, j" tanks,buildings;indicate distance on plot plan) ❑ 0 Are there roads within a 100-foot radius of the water source? "4 Is the road Private,County,or State?(circle one) Distance to the road(s) 0 0 Does the ground slope away from the water source site? ❑ 0 Satisfactory well cap? (�f ❑ ❑ Well cap screened and vented? i\ JT ❑ The well casing extends ` Z above level _.oun s concrete slab?(circle one) )6 0 0 Evidence of a surface seal? Lat: LI Y 11,46 46 0 Adequate surface seal? Lon:—1 zi_rat 1 0 0 Variance necessary for well site approval? Tag: Q e e ra Comments: 6Pass ❑ Fail Inspectord'2 Date 167?6/ZDi Review Step 2: Two-Party Review: YES NO NA 6711(ZOl11 go ❑ ft ElWater well report(well log)with a concurrent capacity test?t141( 7' ❑ 0 Nonconcurrent/separate capacity test? )� ,,i/ �I Capacity test information: Date 3!3(l w 7S Driller �� la 1)/rt�!'L //��� y/ FA, 1'ClouP� #o Sf��- GPM I T Duration(minutes) 6 0 Total Gal YW ( y Yet�wzS cent �� 1�+��fe.. ❑ ❑ Satisfactory bacteriological analysis? Date of test 7 7 0 0 Signed,notarized,and recorded notice to future property owners?AFN ^�.1- `._ 564.0 0 0 The system appears adequate to serve two conei4ie llyed on the information provided? Comments: 4)0 �9 SFp �� uH000� 63?0 oe — Approved ❑ Denied Reviewer 7y 1jr Date �l3 G 0/,�oN07F,yt Findings in this review reflect observed conditions as they existed on the day of tpi jj'i�spection. 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 arc 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 2of2 WATER WELL REPORT DEPARTMENT OF Notice of Intent No WE35727 ECOLOGY Unique Ecology Well II)Tag No. BB8328 T of%1ork: State of Washington Type Site Well Name(if more than one shell) 7 Deconuniasion c=4 Original installation NOI No — Water Right Permit/Certificate No Proposed('.se: IR Domestic LI Industrial ❑Municipal Prolrcity Owner Name Dylan(3itbert .J Dewatcrinµ Irrigation f7 last Well ID Other Well Street Address 90 NE Pine Camp Road Construction Type: Method: E New well C Alteration h Drisen ❑Jetted L.i Cable Tod City Belfair _____ County Mason 0 Deepenmlt 7,2 Other G Dug lig Air- C7 Murd-Rotary Tax Parcel No. 22311-76-00390 Dimensions: Diameter of boring 6 in.to 164 R Was a variance approved for this well? 0 Yes ©No Depth of completed well 163 a. If yes,what was the variance for'' Coostruction Details: W all Casings Finer lhameter Front to thickness Steel PVC Welded Thread Is 1 I'' 6 in 0 163 , .250 in N i C7 E) I G location(see instructions on page 2) 51 W WM or C1 E WM 1 i:_i in _ in. ❑ I 0 DID SE !is-%of the NE %;Section 11 'township 23N Range 2W I. in in. ❑ I ❑ ❑ I ❑ 17. in — _in. CI I ❑ 0 I 0 Latitude(Example 47.12345) 47.499553 Longitude(Example:-120.12345)._122_887315 - Perforations: 0 Yes (i No Type ofperforator used ____ Size of neili)ratinns in by in Drillet's Log/Construction or I)ecommi;sion Procedure of perfxatiors ! ---- fnxmation Describe by coke.character.size of natoiat and stroctme.and the kind and Pertr rued from R.to R below ground surface nature of the material in each layer penetrated,with at(cast one ern)for each change of Screens: :_i Yea lit No 1)K-Packer c Depth fi information l:se additional sheets if ncscsaary. Manufacturer's Name_ __--- ------- -__..._-.----- Material From To Type Model No .....-- Diam etct Slot site in from ft to_ti Brown silty sand and gravel,cobbles 0 4 Diameter_ Slot size in horn ft to ft Brown silty sand and gravel,loose 4 19 Brown siltbound sand and gravel tight 19 31 SandTilter pack:I Yes $No Size of pack nutenal_ in Brown silty sand and gravel,loose _ 31 54 Materials placed front ft.to. ft. Brown silty sand and gavel,loose,wet 54 60 Surface Seal: I Yes 0 No I o what depth? 18 ft Brown silty sand and gravel 60 122 o Saaterial used in seal Bentonite Chips a Multicolored�ravei,fine to medium 122 is, Did any strata contain unusable water! 0 Yes Li No -- --- = Type of water? Depth of strata _ brown sand,wet 154 Method of seating strata on. Multicolored gravel,medium to coarse - 154 sand,loose,water 163 •` PAP Ptah iai(futcr's�9j1C 1.`pe Brown silty sand and gravel,dry 163 164 o II P. Pump intake depth: ft Designed flow rate g ran c Water level: lard-surface eksanon ribose Aeon sea loses 441 ft E Stick-up of top of welt casing 1_ft abuse ground surface o Static water level 134 R below top dwell casing Date 8/14/19-_ s-i Artesian pressure lbs.per square inch Date ______ ia Artesian water is controlled by (cap.sake.etc./ --i____.._._- o W eU Tests: c - W as a pupi performed'?ng test performed'? E7 No ❑Yea try whom?? --- RECEIVED Yield gpm with—R.draw down after lus - - o 2 Yield ___gpm with_It dtawdown allot_____his et) Yield _ ppnm with It draw do.n after Ms .5- Recovers data(time rem when pump is turned off-water level measured from well SEP 1 2 f1 f) toptowatcrkvel) _ �T�J Z�js� Y- P Time Water I es el Tune Water l escl l mite Water l csel s ri{'-etao t Y.VI'j s7 Department _ — 0 Z Date of psrmpiog test vs c Hailer test gpm with fi drawdown slier_his Au test 20 spin with stem set at 160 11 for 1 tins Date 8/14/19 e' Artesian flow_gpm ,..I u Temperature of water 48 .F Was a chemical analysis made? ID Yes IT No Start 1)-ate 8/14/19 Completed Date 8/14/19 — u o WELL('(1NSTRt'(`l iON CERTIFICATION: 1 constructed and/or accept responsibility for construction of this well.and its compliance with all Washington well d construction standards Materials used and the information reported above arc true to my best knowledge and belief E a AI Driller Li Trainee 0 PI.--Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. o S£ruturc _ Address PO Box 1790 ci License No. 2874 ��/'/ ---- C'ih.State,Zip Shelton.WA 98584 IF TRAINEE:Sponsor's License No Contractor's Sponsor's Signature Registration No ARCADD1098K1 Date 8/20/19 ECY 050-I-20(Rev Ot)`18) If you need this document tit an alternateJornrar.please call the Rater Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service Personas with a speech disability can ca11 8 7 7-8 33-63 41. Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Joshua Munderloh Well Tag #: BBB328 Site Address: 90 NE Pine Camp Rd, Belfair Depth: 163' Date of Test: 3131/25 Static: 132.9' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 15 133.6 TIME LEVEL 2 Min 15 133.6 1 Min 132.9 3 Min 15 133.6 4 Min 15 133.6 5 Min 15 133.6 6 Min 15 133.6 7 Min 15 133.6 8 Min 15 133.6 9 Min 15 133.6 10 Min 15 133.6 15 Min 15 133.6 20 Min 15 133.6 25 Min 15 133.6 30 Min 15 133.6 35 Min 15 133.6 40 Min 15 133.6 45 Min 15 133.6 50 Min 15 133.6 55 Min 15 133.6 1 Hr 15 133.6 Total Gallons Pumped: 900 lo1ottuIHJltlttl t '� 1 TACOMA,WA 98404 (253)531-3121 WATER BACTERIOLOGICAL ANALYSIS ,Astiki crLtECTi-it IlkAil fS1NLFtlINS UN .; ., . If instruction are not followed,sample will be rejected. DATE COLLECT`E�D_ 3 TIM TW COUNTY NAME MONTH l / - TYPE OF SYSTEM IF PUBUC SYSTEM,COMPLETE D Pu lC CIRCLE GROUP I.D.No. DIVIDUAL A 8 (soo s wily 1 residence) - , NAME OF SYSTEM CY/03 M xv OE 10 k LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. h (is.kitchen tap a school,fire station.fountain) DAY (3{{�)��-U - 3 i 5 e7Bg3zce - qo N� , P)t-e CC r P Rd,�?c'tfa i r EVENING( ) SAMPLE� I.L COg TED BY:(Name) SYSTEM OWNER/MGR. (Name) —— SS ck n SOURCE TYPE 0 GROUND WATER UNDER SURFACE INFLUENCE 0 SURFAC9kELL or LL FIELD 0 SPRING 0 PURCHASED or INTERTIE 0 or OTHERTION SEND lens` TO: i c` I ►sng?c v c,rl \-a& gtrCO3(\%CI(1ik flca•COP-1 WASHINGTON TYPE OF SAMPLE(check only one In this column) ❑ DRINKING WATER 0 Chlorinated(Residual:�Total Free) ii check treatment -7 ❑ Filtered 0 Untreated or Other ❑ REPEAT SAMPLE Previous coliform presence Lab Previous coliform presence Date i �— ❑ RAW SOURCE WATER Saur e# o I B Total Conform 0 NEW CONSTRUCTIN or REPAIRS �y,� Ft cat Colitorm OTHER(Specify)'t 't Ui i C-A."CAI Uh� REKS LABORATORY RESULTS(FOR LAB USE ONLY) METHOD USED MF I MPN 1 PA I ` MMO 1 CPRG I 2410 l 2600 I 2610 I (...22.9.1 2730 TOTAL COLIFORM /100 ml E.COU /100 ml FECAL COLIFORM /100 ml HE)EROTROPHIC /per ml 1a40 ANOTHER SAMPLE REQUIRED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑Sample too old 0 Confluent growth ❑WrUN container 0 TNTC ❑Incomplete form 0 Turbid culture 0 0 Excess debris DRINKING WATER SAMPLE RESULTS 0 UNSATISFACTO)V (forms present SATISFACTORY, iforms absent REPEAT 0 E.Coli present 0 E.Coli absent SAMPLES . REQUIRED 0 Fecal present 0 Fecal absent ' :-.I.I .!F.Vi_'r`_l •,il„ - 'i _ • -r:ii EXPt.ANATI'31•i LAB NO. DATE,TIME RECEIVED RECEIVED BY 089 7 (( 41. 3 0 . DATE REPOT TI ROUTE ACCI• 2228660 MASON CO WA 07/29/2025 10:49 AM NOTCE JEFFREY BOUDREAN #212362 Rec Fee $304,50 Pages 2 Return To cJe re ,4(1�✓'e a Y , 90Nc /2,. 0 / co, 3 • Grantor(s): (1) FT%-f ( . BCD 4--,A Grantee(s): (1)PUBLIC Legal Description (1) 514 7 3 A (A bbreviatedform:i.e.lot,block,plat or section, township, range) Assessor's Tax Parcel: (1) ' t 1 7 ( — O n 3 g' Q 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: / G Tax Parcel: (Connection 1) 2 o2 3/ 0 Tax Parcel:(Connection 2) 2 02 3 //— 76— O a 3?a The system owner is responsible for keeping this system in compliance. The name of the water system is: pi—Ma tol 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 9 Ll day of ,20 3—_ Signature of Grantor(s): (1) 17/-1gly)„3:55--- ,(2) Page 1 of 2 State of Washington County of Mason 1,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this 2.4 day of �i,.( 1.7 20 y5 , 3 f- f C.p 13 o lA d ire a(/`lersonally 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. `,,,,,,qu urp,Ml. 14-. KRUGF�.,,1 Notary Public in and for the State of Washington, 4\Ss�ON F Oi• •,, residing at 5 e j YC, i ( r. �4 NOTARY 4�"a: _ DI, e �-52 2�: My commission expires: 20112949 PUBLICS•••.,_= Page 2 of 2 s ..4 . . 14- "' NIP O 1 44211r .. r . ;T A a. • • t •^ Rpro4viat �',4 /tunoo uoseW woj petuud . , S ,A,, 9 t6Lu o' uo o , Oa1uiJd y. n,E ptncGowtQI?d. ' Ci • 610PCo, .•' . :IS ' A St 15• o sb 4 tee 6 FS-I9Cg 1+ . . • • .9 .. Nitts•Rhacco.WWI' .. :: a��•• • •, 0• . Ltd ,10 NE. PiAt Capv RA car fvr-t .• d,v tri c tt •}rondnt5 • . . ®•s`oto. \i\gio z ?___7 too' • dad.'• ' '.°� - - --- . S�o� . . • /0..T.— • • • 0 Audia-Viacud Alm • i CkV ) 3Clasnout - ® 1200 Gan=Sep&Tank • 0 1000 Gaon Pp Comber • © Valve C«zaa 80c •/ 1 Il •I '/ f . '� '�1 f • ..,•. Pw UlA.JOY JOHN60N t Prirred from Mason County : MS Printed from Mason County DMS