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HomeMy WebLinkAboutWEL2025-00102 - WEL Application, Design, Letter - 9/24/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 J L BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 09/24/2025 DEWEY NANCY 1830 E BROCKDALE RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00102 XX SE Dusty Ln 319027590033 The 2-party water system, The Rosemary (319027590033/319027590021), 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 ' Date Received: enilTalbT,. MASON COUNTY 68, 91 a5 �-� COMMUNITY SERVICES Amount Receivedy 542 0 I Rived By . Building,Planning Environmental Health Community Health F 415 N.6'Street,(Bldg 8)—Shelton,WA 98584 WEL o90o5- oo l oa Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION I PHONE( 3s3 APPLlCANr MAILING.ADDRESS-STREET,CITY, I� YY ock eI�t-le ?A NliEcEmE SITF.ADDRESS-STREET,CrrY,STA'I'h:,%JP L0k 33 C/� ���� / „` PRIMARY PARCEL NUMBER(WELL SITF.) l_ AUG 19.2025 3I qo2 --1S g0033 SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) I III . . 3I �Z�q ^15 — 9Oo21 By . WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE(no mt, • ' - " �New Existing j Well I Spring I„Q,2 cures. . . 1-$2 acres' PROPOSED WATER SYSTEM NAME(REQUIRED). The eo5c -o - / PROJECT DESCRIPTION(e.g.,detached ADC,new single-family resldeace,existing connection,etc.) Nevi Cor rvGi" or DIRECTIONS TO SITE/CONDITIONS I GATE CODE/KEY LOCATION/ETC. Hwy lot ., Lefton, L,\jr,t;1-►,, Lefton ?h;11;Qs Rd R 1,-1- er- 'lost/ Lln) Lot On eriY C (z()2 1 enpe,rr-j or r 60- 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.) fee oftt eck 0Di- plate Required Submittals Checklist: (additional information located on the first page of this packet) lYk,Satisfactory bacteriological test from within the last year ti 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 are no septic records on file) This form may be scanned and made available for public viewing on the Mason County website. Revised:07/23/2025 Page I of 2 Staff Use Only Review Step 1: Well Site Inspection: YES N/O 0 ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) ❑ t 0 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? ❑ ❑ Satisfactory well cap? XI 0 0 Well cap screened and vented? I. , "' 0 The well casing extends 1G above level : •und/,sncrete slab?(circle one) yr 0 0 Well tag attached to well casing? Lat: 41.1014 ❑ jr 0 Lon: -1Z3.o1ffII Evidence of an adequate surface seal? ❑ 0 0 Variance necessary for well site approval? Tag. BWnr V3 Comments: .- f Art Sofet to 1 Ci�t beet lee p ado f y/t /t�zs : &Mi ,�,b s o f ve(( )t. *ce- sari . t)44 . Date !! �al�07� ass ail Inspector Review Step 2: Two-Party Review: YES NO NA ?�t /j0�15 �0(l r4• �ir� 4 ❑ ❑ Water well report(well log):Date Completed T(JD[ w Driller y'1 ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level withi 24 hours? Capacity test information:Date PIN W tS _Driller/Pump Installer hAm i" k4(my GPM 17 Duration(minutes) `©✓ Total Gal I ` ( 5.- Recovery Time(minutes)to Static S 0 0 0 Satisfactory bacteriological analysis? Date 7(ZOO2 Testing Lab kitty firth ieb 0 0 Signed,notarized,and recorded notice to future property owners?AFN Z Z 300 L( I ❑ ❑ The system appears adequate to serve two connections based on the information provided? Comments: 7Approved ❑ Denied Reviewer Date (ZY7�l✓ 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:07/23/2025 This form may be scanned and made available for public viewing on the Mason County website. Page 2 of 2 WATER WELL REPORT DEPARTMENT OF NoticeoflntentNo. WE59626 ECOLOGY Unique Ecology Well ID Tag No. BNM813 Type of Work: State of Washington O Construction Site Well Name(if more than one well): WELL#1 O Decommission t=> Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic ❑Industrial 0 Municipal Property Owner Name DEWHILL HOMES LLC ❑Dewatering ❑Irrigation ❑Test Well 0 Other Well Street Address DUSTY LN Construction Type: Method: E New well ❑Alteration ❑Driven 0 Jetted ❑Cable Tool City SHELTON County MASON Li Deepening ❑Other ❑Dug O Air- 0 Mud-Rotary Tax Parcel No. 319027590033 Dimensions: Diameter of boring 6 in.,to 180 ft. Was a variance approved for this well? ❑Yes E No Depth of completed well 180 ft. Construction Details: WallIf yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread El I C 8 in. +1 170 .250 in. O 1 ❑ 0 I ❑ Location(see instructions on page 2): O WWM or❑EWM ❑ I ❑ in. tn. ❑ 1 ❑ 0 I ❑ NE '/.-/of the NE %;Section 2 Township 19N Range 3 ❑ I ❑ in. in. ❑ I ❑ ❑ I ❑ ❑ 1 0 in _ _ in ❑ 1 0 Cl 1 ❑ Latitude(Example:47.12345) 47.16914 Longitude(Example:-120.12345) -123.01593 Perforations: ❑Yes ❑a No Type of perforator used No.of perforations Size of perforations_in.by in. Driller's Log/Construction or Decommission Procedure Perforated from R.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: )Yes ❑No [K-Packer Depth ft. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type STANLESS Model No. Diameter 6 in. Slot size 10 in.from 170 ft.to 180 a. CLAY&SAND BLUE 0 95 Diameter in. Slot size in.from_ft.to ft. CLAY&GRAVEL W/WOOD BLUE 95 100 CLAY&GRAVEL BLUE 100 115 Saud/Filter pack:❑Yes a❑No Size of pack material in CLAY&GRAVEL WOOD BLUE 115 130 Materials placed from ft.to ft. CLAY&GRAVEL BLUE 130 160 Surface Seal: l Yes No To what depth? 20 ft. GRAVEL H2O BLUE 160 180 Material used in seal BENTONITE Did any strata contain unusable water? i I Yes [N No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name GOULDS Type: SUB H.P. 1 1411 Pump intake depth:180 ft. Designed flow rate: 1a gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 122 ft.below top of well casing Date 8A-25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? 11 No '' Yes b by whom? Yield 19 gpm with 14 ft.drawdown after 4 hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time-zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test gpm with_ft drawdown after_hrs. Air test gpm with stem set at ft.for hrs. Date Artesian flow gpm Temperature of water °F Was a chemical analysis made? ❑Yes O No Start Date 7-21-25 Completed Date 7-30-25 WELL CONSTRUCTION CERTIFICATION: l 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 Trainee❑ PU—Print Name MADI TROTTER Drilling Company COOLWATER DRILLING,INC. Signature ��y Address 10921 NW HOLLY RD License No. 3367 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.COOLWD1941QM Date 8-2-25 ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 360-830-9005 4&6, <2 COOLWDI941QM 'k, 4 Fo CUSTOMER NAME DATE 8-4-25 DEWQHILL HOMES LLC CUSTOMER ADDRESS 319027590033 TIME STATIC GPM TIME STATIC GPM 122 05 133 19 120 136 19 10 136 19 135 136 19 15 136 19 150 136 19 20 136 19 165 136 19 25 136 19 180 136 19 30 136 19 205 136 19 45 136 19 220 136 19 60 136 19 235 136 19 75 136 19 245 136 19 I 90 136 19 105 136 19 RECOVERY STATIC RECOVERY STATIC TIME 136 TIME 05 122 30 10 45 15 60 gi 20 75 25 90 4 26276 Twelve Trees Le NW '} Ste.0 SPECTRA Laboratories- Kitsap Poulsbo,WA --J ...Where's}erias=matters 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected oe I ?5--1 2 com /yr'� Month Day Year d I7 PM 9 or "-� Type of Water System(check only one box) 0 Group A 0 Group B Dtther Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): System Name: d ij Contact Person: Go c t t v s fit R L LL r - Day Phone: 34,6 g 3 D_ 9.0 O-�- I Cell Phone: _ Email: l Eve.Phone: Send results to:(Print full name,address and to code or'mail obeys for electronic copy of risotto) eo0L 0rtz?'C L 21...(e /10 14e- (.¢-c SAMPLE INFORMATION Sample colected by(name): coot-IAA f Specific location where sample collected: Special instructions or comments: Qos y Lr' Type of Sample(check only one box) T, 1.❑Routine Distribution Sample(AY) 12.❑ Repeat Sample(AIP) Chlorinated:Yes 0 No 0 (from distribution system after umat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total_Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: ISI Chlorinated:Yes No ❑Triggered(AIP) Chlorine Residual:Total_Free_ ❑Assessment(NP) 4.Surface or GWI Raw Source Water Sample(Enumeration) ❑ E.coil 0 Fecal Filtered Yin No 5.[ ample Collected for Information Only Li Private Residence U Consbuceoni weirs LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and XSatisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform mpn/100m1.E.coli mp&100nl. Fecal Coliform cful100m1. HPC cfu/lml. Replacement Sample Required: ❑TNTC ❑Sample too od ❑ Sample Volume 0 Damaged Container 0 °$ �S�"2;5- NM mr 135� iS Y 0/ Receipt Temp C': I Method Cod F-`Cf ��OT-COUNT!SM9222D Dale In: { DateOut5 MI5 � 205 nil mode Fond waMparan«aarapnyn ff�lt1111UU1l/UUP! 6 rtmrnaddromn1 yur.mrigrMamearhnMM mps,in yew roar be inmate*s 7ED7JYSU1 Ind l nanny Ha rWat voMh. DOH LabSample# /� r/O mo d op u tin arty bMhn ION WMamOiwdu ..11 (_•I/I t_1/ WINN IN Me UM /.7lienpsl�robs tepee meet Os r (]1�• nlu..tDew pear sows loam spapNby Sondra tabaiis. DOH Form innate(ado owl) 2230049 MASON CO WA 08/2912025 11:21 AM NOTCE 1 a�Mill� 11II N fli 11111P88 Rec iiuu 11311111111 $304.50 Pages 2 Return M. 6vI c.1 V flAxm 4062 9 2025 I ' 30 E. 13 cockdatc, tect REcE,fro) slut. 1 LA.) �t 85fs�1 Grantor(s): (I) iU 'Pew(A3 ,(2) N6.11 cPeweA3 Grantee(s):(1)PUBLIC Legal Description (1) I r 1,. S P S8 3 !r I vF S t° 's8'4 Sol-T 19- 1Z..3 (Ahhrel'iated form:i.e.lot,block,plat or section,township,range) Assessor's Tax Parcel:0) 31 9 0Z- 75- q v o 3?) 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 desigf}ated to serve a source of water to the following parcels situated in Mason County,State of Washington;herein described: Tax Parcel:(Connection 1) 3 ++ CI O Z — S - `"��++1 0 0 33 (4e(.I ) Tax Parcel:(Connection 2) 3 ► 41 0 Z — c CA 0 f The system owner is responsible for keeping this 'system in compliance. K- The name of the water system is: l (r1� oSGh^[,-"Ai This system is designed to p,yovide for two service connections. Planningni 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 Yft.1 USTL ,20 . Signature of Grantor(s): .t&(1) ,(2) Page 1 of 2 State of Washington County of Mason i,the undersigned,a Notary Public in and/ for the above named oynty and State,do hereby certify that on his , day of AL4k t it.6 t a ✓ personally appeared before me,who is known to be signer of the above instrujient,and acknowledged that he(she)(they)signed it. GIVEN under my hand and official seal the day and year last above written. . c______y "ig° ° til Notary Public and for the S to f of Washington, TAMpRA l HERRING Notary Public residing at t'j{�o i✓f/mk r i— t ke State of Washington My commission expires:CI09 (?/ 1,v 2g Commission#41438 My Comm.Expires Jan 17,2029 • Page 2 of 2 f the 1COSEMPIRN- 3S _ 91",.c90seD. 2(0t0_ 86 \O P t00 i • b' ,--''--* 1111i., - A I 1) t%) ‘..L.o.i 13 '1 ----- 11,11 ;,.:11::,. ;1 1. L/i‘likiz\ 0 .1 • :. A i 1 :,. { !Iss.cr t ' 1 CX% i i I ll II 7 s QC 02. I: ! I Ae- '30---1 s„ o I 115. -r(z,tN 0-iss G Z. ‘A WITH 06. E 1� 5 -�'AD N L s a a .E5i•ttom' G PR\v-A't— . R.D S 1:::,0Tn E..srNE I Sc.Pct- � .. _ y� , O so Ao 40 $0 .see: LOT p Pc.f�N O Audio Visual Alarm Da-U. #1 L-L 9-LE S 0 Clear out CE,Z Pi-3‘a 02�7 S- R no 3 - _ O 500 Gallon Pre Trash tank St DGsr P O NuWater BNR-500 ATU Tank ci��tTO � k�� L?ES�4. Q {Jos cE 0 1,000 Gallon Pump Chamber 21./24 n L S T-.O frto-rr-- 0 Valve Control Box 2 : 22" L S -\---o f ZtoCe.Qq • op,- osl 5 ' pt.1Nm.,DP.i — --— !Ill ad Df,C� Vim` 100 '�e�¢1Pof 5�P ` 1 N ofk �RoYoS�fl W Eta- L 3 3tR 1 I ti15 dG A •ill& - _ ___ ._ it ek 3' XSO1 pRt /1 .`• 1145Loff et ' 0.c. LA, rt-vt 6.Ec2C e.,)c 4, Ld f V \ s-rIrjv PfztV -t-S 2°fi /466---(4' I S e Du ST L I i 25SA I�eP SCR-f�� !�• �� ! A 0 Audio-Visual A?� qo b`o 8° ° ''c t�1IF 2 Cieanout LpT P Lp IJ t O tank LL S .° i h 3 500 C,allor.Pre Trash '�-+2 C.iL �jl G2 ; J_, ' '•.`�y�f �, NuR+ater B 49 S`G D�}5 F JCYJO f SON :., O 1,Qd Galloo,eicin �.e4c� S�LTOti C � W "�' haniber { i }{OL E pws O Valve Conte of Box " czoerrscR•S1DE) 0 LD ,-{ 'DA-ZS 8020 PlL )'C i * . 21 ,, Ls -� NA -ail 1 LL G D APPR 1UN 0OVG5 2 202 MASON COUNT ENVIRONM�ENSALN��TH Printdm Mason County DMS RED Printed from Mason County DMS I'l i