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HomeMy WebLinkAboutWEL2024-00045 - WEL Application, Design, Letter - 10/3/2025 ter■ 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 10/03/2025 MIELKE TYREL M & RICHELLE R 261 E KARI SCOTT LN SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00045 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 or— D C7[1W._:- r . ` OCT 1/ 2024 IJ .�\, MASON COU '=�� ' it Date Received: /O I 3/ / n �` -�11 ' i COMMUNITY SERVICES Amount Received: Received By: Ci = 1 5y5 Building, Environmental Health,Community Health %t; 415 N.6`h Street,(Bldg 8)-Shelton,WA 98584 W E L 2024- 600 '15 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 F.Irna:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE TvNN ADDRESS-STREET,CITY,STATE,ZIP 1,lZIP IC t \ awe_ -- e`er., I I\d C\i�C�LA SI E ADDRESS-STREET,CITY,S STATE,ZIP 1. (t 1 0 1-wr; s C e A-1C \ A r-e N.,:a-\,c-or i LAD p ittg 5 gl"{ PRIMARY PARCEL NUMBER 33�SITE) O O SE�ONDARV PARI NUMBER(IF APPLICABLE) 14D 0 ‘ R-a‘3sOt 10 WATER SOURCE SOURCE TYPE PARC16.1 L T SIZE PARCEL 2 LOT SIZE i New 0 Existing Well ❑ Spring S ' .{�t, - 11 PROPOSED WATER SYSTEM NAME(REQUIRED SS O{^V\ 1. -) C'_. PROJECT SCRIPTI N "TWO (�cc ) \ e \\ S i. ,�\-Cim - -oc- 90.“-eA. \ o\ (e")- SOO "(9a \ 0\SK.D. `cbtkO DIRECTIONS TO SITE)CONDITIONS L,roS5 VA'a + ,'-g,G .iLrV.,,�V. E SD04-.7„,) A. M4t v l-e V 4 e vkl- R .10, k\X \A E trAkc e V-:y\-,sc- et eAN Qk \4-.,r-. SCM4101 Site Plan: (may also be attached) (property bo -1.:- ructures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) • r 4/%'3 bat)( G.��e��� \' Say 4 c4:;_ i v. 1 0, 1 .S. 4 It _2'1-3 , 4,72r .. ...--------). 44 s hi g. Submittals Checklist: (these additional items will be required for approval) rgf Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) [if Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) Iv k IX 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 Review Step 1: Well Site Inspection: YES NO NA ❑ El Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ke'aq ❑ ❑ Are there roads within the 100 footsadius of the water source? If so, is ro.: privet- County or State. What is distance to ROW? ~36/ Z ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ I( ❑ Is the well cap satisfactory? - CM;11,o'1 I,yW 0 7 ❑ ❑ ❑ Screened and vented? ❑ The well casing extends 2 l above level .roun. / concrete slab? (circle one) ❑ TA ❑ Is there evidence of a surface seal?� Wt soda fb 01: 4 7• 2 2,3?- ❑ ❑ Does the seal appear adequate? $ftvrd lave i cal:dd-I ZZ. 0 ?V ❑ ❑ ❑ Is a variance necessary for well site approval? J ! /11Cc 3afl Comments (Q 11( Z0 ZS RCCe ttaPl , "frcri Qpfjbl4F-OF U'(i« ceeee to ro,e (oitt Passil Inspector Date ' 1 a/?aZ y — c Review Step 2: Two-Party Review: YES NO NA -(1 ❑ ❑ Water Well Report with adequate pump test on file?Data" O,.7, oil 2/o2/201r w/ 156Pi'�fpr6001t✓tef l�f ( %OM.l) If NO, date of Capacity Test Driller GPM KI ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 7/1f/&yY ir ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2II 77-fc [r ❑ ❑ System appears adequate to serve 2 single-family residences based on informa Rrovided? Comments Piy `�°Nco� 1 o 3 �0 �0Approved ❑ Denied Reviewer Date af�Dip �,4 1„. 446,, 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 /9'h, 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 millilliNIIINMEMINOMMINIMMIr WATER WELL REPORT CURRENT Original&1"copy-Ecology,2n°copy-owner,3r°copy-driller Notice of intent No.WE29864 DEPARTMENT or ECOLOGY Construction/Decommission("x"in circle) Unique Ecology Well 1D Tag No. AKS300 Sme Do Construction Water Right Permit No. _ ❑ Decommission ORIGINAL INSTALLATION mow Notice of Intent Number Property Owner Name Tvrel Mielke _ PROPOSED USE: 0 Domestic Cl Industrial ❑ Municipal Well Street Address E Kari Scott Ln ❑ DeWaler 0 Irrigation 0 Test Well 0 Other City Shelton County Mason VI TYPE OF WORK: Owner's number of well(if more than one) .� LocationSMI/4-1/4nwl/4 Seen_ Twn 20N R IW EWM El. ❑i New well ❑ Reconditioned Method:El ❑ Bored ElDriven (5 r Still REQUIRED) Or 0 Deepened MI Cable ❑ Rotary 0 Jetted ,t, WWM DIMENSIONS: Diameter of well inches,drilled 159 ft Lat/Long Depth of completed we11159 ft_ Lat Deg Lat Min/Sec �',s'R CONSTRUCTION DETAILS Long Deg Long Min/SecCasing 0 Welded 6 " Diam.from +I ft to 159 ft. installed: 0 Liner installed •' Diam.from ft.to ft. Tax parcel No.(Required) 12018-23-50110 ❑ Threaded " Diam.From ft to ft. Perforations: 0 Yes 0 No CONSTRUCTION OR DECOMMISSION PROCEI IUF il tl R Type of perforator used Formation:Describe by color,character,size of material and s:rucure, SIZE of perfs_in.by in.and no.of perfs from ft.to rj, and the kind and nature of the material in each stratum penetrated,with at — least one entry for each change of information. (USE ADDITIONAL Screens: ❑ Ycs 0 No i] K-Pac Location 154 SHEETS IF NECESSARY.) IV IV Manufacturer's Name Machine Alloy Works MATERIAL FROM TO Type Stainless Model No. Topsoil 0 2 Diam s Slot size 20 from 154 ft to 159 ft. Brown Sand 2 130 0 Diam. Slot size from ft to ft. Red Sand&Gravel 139 140 Gravel/Filter packed: 0 Yes © No Size ofgraveVsand Sand&Gravel w/Water 1411 160 Materials placed from ft.to ft. la Surface Seal: © Yes 0 No To what depth?10 ft — Material used in seal Be auflite 3 Did any strata contain unusable water? ❑ Yes 0 No _ e Type of water? Depth of strata —i______- Method of scaling strata off_ PUMP: Manufacturer's Name Goulds i Type:sub H.P. I hn s WATER LEVELS: Land-surface elevation above mean sea level ft r- . Static level 140 ft.below lop of well Date 2-12-2018 MI Artesian pressure lbs.per square inch Date lArtesian water is controlled by _ (cap,valve,etc.) _ f WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump tat made? 0 Yes 0 No If yes,by whom? Yield: sal./min.with ft.drawdown after hrs. Yield: gal./min.with_fl.drawdown after hrs. Yield: gal./min.with i_fl.drawdown after hrs. R t....C E 1 V E D Recovery data(lime taken as zero when pump turned off)(water level measured from well top to water level) - - . . A i Time Water Level Time Water level Time Water Level Mt111 0 5 ZO1U , WA Mate Oepdrtment rte (jVVKC) 0 Date of test 75 Bailer test I5 gal./min.with 5 ft.drawdown after 1 hrs. Airiestinsi til gal./min.with stern set at ft.for hrs. — 15 Artesian flow g.p.tn Date Temperature of water Was chemical analysis made? ❑ Yes l] No Start Dald)1/28/2017 Completed Date 02/12/2018 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Wasnington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. 0 Driller 0 Engineer El Trainee Name Emily Davis Drilling Company Davis Drilling Driller/Engineer/Trainee Signature Address 340 NE Davis Farm Rd ii, Driller or trainee License No.3142 t City,State,Zip Belfair,Wa 98528 IF TRAINEE:Driller's License No: Contractor's Alt Drillcr's Signature: V N_ Registration No. DAVISDD110OA Date 02/12/2018 ECY050-1-20(Rev 02-2010) To request ADA accommodation including materials in a format for the visually impaired,call Ecology Water Resources Program 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 •l. I1T�G7tS'Ii�i\COL'1TTY 412 ally Rd NE Olympia,WA 98506 . 360 867-2631 COLIFORM BACTERIA ANALYSIS i Date Sample Colleted 1 Time Sample County 1 Cai�:ed q i1 ALI i aca. 1 c o P;, yAck son h :Vie ray tt;aa t Type of Water System(chec. only one box). Privelia idaeeheitl 0 Group A 0 Group B 'LOther- - 03G i '7 Group A and Group B Systems-Proa=do front Water Facilities Inventory('NFi): lD# System Name: Contact Person:"r.f c ' e 14.. -e- Day Phone;( 1,`7.") 6c{4` Ce`l Phone:f C�) 7 64 E-mat .I Vol t P Cdt-e41-6-,t++eA:ti Eve.Phone:( ) Send resutrsio (Prig tal_fluve,edeov Ind zip rode ornailedtress) �"..y'' __._I—`__...__....._ _._. ..._)4e.I_-=_ _Y�-�`.A_S_C. SAMPLE INFORMATION li Sample collected by(name); , I. -fi- 4e.t ;,,AA ',. itce l Spec loc_atin or address where sample coveted: Special instructions or comment: tS\ - .kxn, v} N v-S `.S`- Type of Sample(must check only ono box of II1 through 4g listed be ow). I 1.1KRoutine Distribution Sample 2.Repeat Sample(after unsat routine) Ctlorinated:Yes No 0 Distribution System Citbrine Residual:Total_Free_ Chlorinated:Yes. No 3.Raw Water Source Sample Chlo e Residual:Total Frey 0 E.off-GWR OW) ❑Fecal-Sur:We,:,'I,exits, ,r-erer : UUnsatisfactor,rouge l, ,number, rirteree Yes No ' 1 - 0 Assessment Monitoring(A''P) Llnsatistactnry routine collect date: ID Ober . r S 1 i 4.0 Sample Collected for Information Only Investigative Construction;Repairs C9her LAB USE ONLY DRINKING WATER RESULTS LAS USE ONLY ❑Unsatisfactory Total Coliform Present and \IQSetisfactory IDE co.i present ❑Ecafr a►1LAnt No Conform detected Replacement Sample Required: ❑Sam pie too old(>30 hours) 0 TNTC 0 i Bactaral Density Results Total Cel1form .i t COmL E toll .f et Fecal Califon 140Orni Enterococci f1D0 mi. Method Code:O§N19223B OSf f 9222D and me Race-ai. ``-'71 0 Sfa19215E ❑Enlerolee ,177- 1)** Date and TiimeAna:{med: 41 --ic,. Daze Re ccr •74r} jly-... San tNrterP314n for usbe4gew; t Lab Use Oily: 0 8 0 ,—' 1 D F=0331.319 Credis=111= ! 2217775 MASON CO WA 10/31/2024 09:44 AM AGREE MACIEL #203127 Rec Fee: $304.50 Pages: 2 I11011 IIIIII I III III III IIIIII!III 00IIIII IIII ID I I II I III 0III 0II II Return To Gi' • - - o// /e,PS" Grantor(s): (1)—Ty('`eA Xv \ lY ` ‘`e A, , (2) SC? 1 \, �Ai v A Grantee(s): (1) PUBLIC Legal Description (1) Co oR KV. A-LS 1 t,S \ ci (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) \ a Q \ b - - 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) 1 a_Ci1 $ - -3 0 0 ( D Tax Parcel: (Connection 2) \ _Q 1 '1 - 'a. - ,s" p \ a The system owner is responsible for keeping this system in compliance. The name of the water system is: S \-‘,0? l 3 e A1\ 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. p Dated on this (X day of 04. -G\ate C , 20 ,`4L\ Signature of Grantor(s): (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. j ixo,), Signature Summer's People Water System User/Owner Date n-lat ci/ 6/d,?-> • ature Summer's People Water System User/Owner Date State of Washington, County of I e scr, I,the undersigned, a Notary Public in and for the named above County and State, do hereby certify that on this t(v 1+' day of Oc)-obor. ,204/.23,personally appeared before me "fy�c l f� LI Le 4- C lic., Mac.;tt 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. �`� , ;� BRU ",, kW./ u 44it .C7 io NOTARY . S. otary ' • is i for the State of Washington, 209271 r sidin: •t ,Sk4_111 Ill)L ��SS“ N PUBLIC . c 0?-l 7-.ZU� �'.� :°!»r?°:: ° '��y . •• •'ssion expires: 7 � 'IOF'WASN,a INIMIIIn . d Ni 1100S I V>I 3 09Z 48SB6 VM NO113HS woo•�loollno§opu6isepuosJanley 1 'N11.1OJS Riv)I 3 09Z 178S86 eM uolla4S 61.SL Xo8 Od 00.y ,,� OLLOS-CZ-8LOZL #193Jed up,os V V1IOS'1310VW .1„P, ,,K, 011 u61se j uasJanieH'W I I `; I l61 i� ---�-y / j_________ _ .___ ___ ___ .__ _ . _. ___ _ ; _ . . . .') _. _ \ ��• / 111 / N1 NODS I2,It>I 3 -/+,l VG ® / > J 10 cr V / \ Q J t:. 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