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HomeMy WebLinkAboutWEL2024-00045 - WEL Application, Design, Letter - 10/3/2025 MASONCOUNTY 415 N 6TH STREET,SHELTON, ,E 985400 84 SHELTON: ,S 42 TON, EXT 584 0,14, BELFAIR:360-275-4467,EXT 400 --J` Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 10/03/2025 MIELKE TYREL M & RICHELLE R 261 E KARI SCOTT LN SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL 2024-00045 261 E Kari Scott Lane 120182350060 The 2-party water system, Shop Well (120182350060/120182350110), 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 1)' C� F OCT 10 2024 ;L) 7,-; "�� \ /, MASON COU Hale Received: z�f" F. l COMMUNITY SERVICES Amount Received /O ' �/ ^Received By I1 Building.Planning,Environmental Health Community Health (� \ WEL D - 5Oo '1$ 415 N.6'"Street,(Bldg 8)—Shelton,WA 98584 � Z� Shelton: 360-427-9670 x400 Betfair.360-275-4467 x400 Elma:360-482-5269 x400 — —.. TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE M IIyN ADDRESS-STREET,CITY,STATE,ZIP ( 6 S co c k 1, o *-a_ S \.er\ i11 , °`q.ct SI i E ADDRESS-STREET,CITY,STATE,ZIP I (# 1 L �,�-`..r. s c,o A-A. \e...c\-e S`--,2-\, , SAONDAR PARL k) . �g 5 g9 PRIMARY PARCEL NUMBER'WEL SITE) � NU �43 - SE ONDAR PARCL NUMBER(IF APPLICABLE)aa ,o tao 1 R LsoL la WATER SOURCE SOURCE TYPE PARC1I,1 L T SIZE PARCEL 2 LOT SIZE New ❑ Existing DkWcll ❑ Spring l S '�`-'- v 1 i PROPOSED WATER SYSTEM NAME(REQUIRED SS 0 e.,\\ PROJECTRIPTIIN 1a. 0\ q;,- S00 leD \ ac7\ Kbt \o DIRECTIONS TO SITE/CONDITIONS Ls'os5 \--L\ r'• .-5r.... \r ,NV.,:: - E souw,-v_,1.,.•,4 A.R. 9 l-e,lt{ e Site Plan: (may also be attached) (property bo ef', t`uctures,well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc...) It1 T'3°�� 1 �` P atsL `CQ +tom �d `� �.., 4. 3.CO1 -- -e- • �� lde� 1-4 . '7' i g 1 os4 ' oe ) s g. Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) U Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) [id Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) N1 k Septic Records (additional locating requirements may apply if there is a lack of septic records on file) I 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 Review Step 1: Well Site Inspection: YES NO NA X ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) i,Gete/ ❑ ❑ Are there roads within the 100 foot4-adius of the water source? If so, is ro.a privat- County or State. What is distance to ROW? ^10 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ [ f ❑ Is the well cap satisfactory? - Cartei ''F kt it -Open. ❑ ❑ ❑ Screened and vented? .� ❑ The well casing extends Z c! above level •roun. /concrete slab? (circle one) ❑ % ❑ Is there evidence of a surface seal?,>i wt c4.le /16 Ga 1: II 7. 2 Z.3 4-S ❑ () ❑ Does the seal appear adequate? lvvrd lave/ -c n1 : —lit. 0 233 ❑ ❑ ❑ Is a variance necessary for well site approval? J : t dd-,tc you Comments (Q it l Ze i$ . 4celttapbiti65fyori Qpphl F0& vat cut( ( to ,AVACI-, (00 � (�Passil Inspector Date � � �`(la� Review Step 2: Two-Party Review: YES NO NA 4 ❑ ❑ Water Well Report with adequate pump test on file? D11il Os' :'15 01 Zf1�«f w/ iS6pM h If NO, ' j date of Capacity Test Driller GPM f I ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 7/& '/Zd ZL( ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2 Z I 7-ff E1 El ❑ System appears adequate to serve 2 single-family residences based on informs rovided? ��Comments �te 148o 00 °CI o3 Lc® "__,7illi-Ifiq XApproved ❑ Denied Reviewer Date 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. Water System approval is a two-part process. 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`r', 2018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 WATER WELL REPORT CURRENT a ki a i Original&I"copy-Ecology,2''''copy-owner,3'''copy-driller Notice of Intent No.WE29864 UtP.lMrwr or ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. AKS300 Sta.<,rr.w,,,ten Construction Water Right Permit No. ❑ Decommission ORIGINAL INSTALLATION Property Owner Name Tvrel Mielke .,..•. Notice of Intent Number ttilPROPOSED USE: 0 Domestic ❑ Industrial ❑ Municipal Well Street Address E Kari Scott Ln ■tom 0 DeWater 0 Irrigation 0 Test Well 0 Other City Shelton County Mason VI TYPE OF WORK: Owner's number of well(if more than one) Location SW/4-1/4nwl/4 Sec IL Twn 20N R 1W EWM ® New well ❑ Reconditioned Method:❑ Dug 0 Bored0 ven (s,t,r Still REQUIRED) Or 4� ❑ Deepened � Cable 0 Rotary 0 JettedWiVM Q C DIMENSIONS: Diameter of well inches,drilled 159 ft. Lat/Long Lra Depth of completed well 159 R Lat Deg Lat Min/Sec C CONSTRUCTION DETAILS Long I)eg Long Min/Sec 0 Casing Ng Welded 6 " Diam.from +1 ft.to 159 ft. Installed: 0 Litter installed " Diam.from ft.to ft. Tax parcel No.(Required) 12018-23-50110 0 Threaded " Diam.From ft.to ft. Perforations: 0 Yes Q No CONSTRUCTION OR DECOMMISSION PROCEI DUE 3 1 Type of perforator used Formation:Describe by color,character,size of material and s:ruc'ure, and the kind and nature of the material in each stratum penetrated,with at C SIZE of perfs_in.by_in.and no.of perfs_from_ft.to_ft. least one entry for each change of information. (USE ADDITIONAL Screens: 0 Ycs 0 No 0 K-Pae Location 154 SHEETS IF NECESSARY.)Manufacturer's Name Machine Alloy Works MATERIAL FROM__TO Type Stainless Model No. Topsoil 0 2 I` Diem.5 Slot size 20 from 154 ft.to 159 ft. Brown Sand 2 130 O Diam. Slot size from ft.to ft. Red Sand&Gravel 13'1 140 Gravel/FIlter packed: 0 Yes al No Size of WavcVsand _ Sand&Gravel W/Water 140T160 Materials placed from ft.to ft.Surface Seal El Ycs ❑ No To what depth?to ft. 5 Material used in seal 6.ntnnite3 Did any strata contain unusable water? ❑ Yes 0 No — — _ _ Type of water? Depth ofi strata Method of scaling strata off_ _,_ , g PUMP: Manufacturer's Name Goulds Type:sub H.P. I hp WATER LEVELS: Land-surface elevation above mean sea level ft. — Cr Static level 140 ft.below top of well Date 2-12-2018 rel Artesian pressure lbs.per square inch Date _ Artesian water is controlled by ^ (cap,valve,etc.) — 1713 WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump test made? 0 Yes i] No If yes,by whom? Yield: gal/min.with ft.drawdown after hrs. Yield:, gal./min.with_ft.drawdown after hrs. Yield: gal./min.with_ft.drawdown after hrs. \L,,, ( VED - Recovery data(lime taken as zero liken pump turned oJf)(water level measured from 1r well top to water level) - - i Time Water Level Time Water level Time Water Level — MAR 20i8 t W� °tale Dep05artment — — oftWogy t VVR0) _ Date of test i 15Bailer test 15 gal./min.with 5 fl.drawdown after 1 hrs. — kJAiriest gal./min.with stern set at___ft.for hrs. 15 Artesian flow g.p.m. Date Temperature of water Was a chemical analysis made? 0 Yes ❑8 No Start Datc01/28/2017 Completed Date 02/12/21116 CP WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well .g construction standards. Materials used and the information reported above are true to my best knowledge and belief. UJ Driller 0 Engineer❑Trainee Name Emily Davis Drilling Company Davis Drilling Driller/Engineer/Trainee Signature Drilling 340 NE Davis Farm Rd Driller or trainee License No,3142 City,State,Zip Belfair,Wa 98528 IF TRAINEE:Driller's License No: \ Contractor's fit g Driller's Signature: Re Registration No. DAVISDD110OA Date 02/12/2018 ECY 050-1-20(Rev 02-2010) To request ADA accommodation including materials in a format for the visually impaired,call Ecology Water Resources Pt»grain at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-83-.-6.i '1. 412 Lilly Rd NE.4 Olympia, WA 98506 360 867-2631 THURSTON COLXT' COLIFORM BACTERIA ANALYSIS Date Sample Collected T rme Sample County Collee..ed c m Gay- ''ax Type of'Neter System(shed(only one box) t'riratallweehcid- ❑Group A ❑Group B -�O her t 7 Group A and Group B Systems-Praido from Water Facitlies Inventory(4VFi): 9D System Name: Contact Person7I-Ci c'-e..k ` Day Phone:( c49 "77 ) ( '-t 4k, CO Phone:f -C..'}-)77 6q4 P ti1c- �5. - s,+�:�-:1 E'e.Phone: Seo eesuts to-Pill fut a'ne,adoesp end Up code cc e'nail address) \irk , s tA) .t , c:arm SAMPLE INFORMATION • Sample collected by(narnei: - Specfd localan or address where sin le x ected: r Specie:instruct-tons or comments: 1)--t �C„ Type of Sample(must check only one box of r1 thrcJgn a listed b tew) 1.KRoutine Distribution Sample 2.Repeat Sample(after unsat routine) p Chlorinated:Yes No ❑Distribution System Chbrine Residual:Total_Free_ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free E.ea-GWR(A,P) DFecal-Surface zwt.exrse:nrerativ* , Unsatisfactory routile lab numtpr. Finered Yes No - rssessm tMonitoring(AP) Unsatisfactory routine collect date: ❑Other S } l 4.0 Sample Collected for Information Only Investigative Construclion Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Cc-:tform Present and '`Satisfactory ❑E.ca4 present ❑E.cofi eight No Coliform detected Replacement Sample Required: ❑Sample too old(>3i0 tours) ❑TNTC 0 ii Bacteria4 Density Results:Total Caiorm a100mL Ecofi t1t7f)mL Fecal Coliform i COml Enteiococcl f1OUreLA Method Code:' Sltii 9223B DSM 9222D and Time Reek at t D Styt 92158 ❑En:erole - O Date and lime Ara'ynert �� t.l- D4re Regetek.r r 1;„4 Y•- — �hmot Hx:tertDSH rumbr s 'r Lab Use Only: kk COX Farr 111331-119 Ocrife:1 T1,7:3t R'tl 2A7- i0-71 1!✓., 2217775 MASON CO WA 10/31/2024 09:44 AM AGREE MACIEL #203127 Rec Fee: $304.50 Pages: 2 II III IIID I liii III I III 11 illl II II Return To 11 ' • F _ /&P'S's 901' Grantor(s): (11T ('`e,l 'f" \ 1" , (2) 1 4,1, .., A'(" Grantee(s): (1) PUBLIC Legal Description (1)7 k:k bS cS \`I 1" `, (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) \ \ g - - S 0 0 to 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) a I\ $ - -is a 0 (p 0 Tax Parcel: (Connection 2) - - p \ 1 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: \-%.1) \ ULD 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 UCA-6\0_li C- , 20 Signature of Grantor(s): (1) , 1 (2) Page 1 of 2 The parties herein agree to establish the right to make reasonable regulations for the operation of the system,such as termination of services if bills are not paid within 45 days of the due date,additional charges for disconnection, reconnection,etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges of 18%per annum together with all collection fees. 1\ V Vjtt...---------_..._____ i OP (4 ic)..0;‘- Signature Summer's People Water System User/Owner Date /0/ / 6/d> (4_P,C A..1 m /cif Date ' ature Summer's People Water System User/Owner State of Washington, County of Mawr, I,the undersigned, a Notary Public in and for the named above County and State, do hereby certify that on this l(o W day of Ocr-ob�►' , 2041.23,personally appeared before me Tycl NV EA kz. -I- el,„„ MaL.,.tl to me known to be the individual described on and who executed the within instrument, and acknowledge that he(she) (they)signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. — �:�'� NOTARY'��N:: otary is • for the State of Washington, 209271 e r sidin t ,Slnl 11 n IA , cS$u ,_N PUBLIC lii y c •ssion expires: 07-l 7-,2_C.T77 9 °j!nrzo?� 'GA o•'• .,,,,.,,,,OF,WAS' ""'" 03.loorinoollu6isepu0sJanley '"a NiNl 1100S 12lV0 3 09Z V8586 VM NO113HS N1110Os IaVN 309Z V8S86 eM UOlI81IS 6LSL XOS Od —„, ,,\, OLOS-£Z-8 1.0ZL #IaU1ed iqui.ms VVIIOS'l310VW .1e„idab,,, ,U 311 u61sa4 uOSJaniek•A ln I y u `�J r/ -- --�_ _ I -. 1- , z A -o — � I / - / so N1 1100S I2ib'}I 3 N i J ...1 ._ . --- - _•w m 14 0 ' I ..... '- it G- i C r�l + - ► < � _ • o I. I f U \ ♦Z 1! \ \ e3 \ ; as • • rn i --- .i-i ,-.4 ild i - c R •1 0 M o a R Z;--I( a .1 oIFS Y N- cc °-a h u. �- ; ,t O �. 1 O } - U F N O A .a 1 � (13 m 3 � ' . E W h - -3 0 N 0 � d 7 > 7> JG n S.)Uv v UM N V V ON c o aOOd C NO , M OQo• 9 3 J O O Q UO O y I • .8 �0pN XO - N t7 f1� II Q SQm (/). F I- 1- �] 9 c • O Net o Q�yW77 O Yt>:c��::-. c0 m E c d ' a■ q �.4 yr. aaWll N N N y . a �Q d V 4- �+ _ ry Q y: _ TOy a gi 4.11 C o.O • W c • .:-.) 0 01 Eiji 1 1.5 d Y. U ,, = ' C U L m O O V b l0 ; U1 7 C _ y p� j T m o a m U Cc o r m m • Q r o T O i t o V O • w F Q > C