HomeMy WebLinkAboutWEL2025-00106 - WEL Application, Design, Letter - 10/9/2025 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
10/09/2025
Dan Hess
18623 Elderberry St SW
ROCHESTER, WA 98579
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00106
150 SE Sister Meadows Ln
319041190020
The 2-party water system, Vizina Water System (319041190020/319041190020), 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
0.10 . --0, 7
MASON COUNTY Date Receved
f .1 1. ' 0 q ' la- zo9-6
COMMUNITY SERVICES Amount Received Receved By
\!y, %/ Building,Planning,Environmental Health,Community Health 04 ,v 144
415 N.6'h Street,(Bldg 8)—Shelton,WA 98584 VVE L aoa� 00 l V c
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT ul N +es 3)ci `1 avV g� _ ~1
AILING ADDRESS-
q...
MI ITF ADDRESS-�STRF,F. F STATE,
1•/� 80 W s IVA-711 ./�`t� >IIV � t'., q
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1$(¢23 et-D ozgew- S i f"/ - i - ( Vril (�
PRIMARY PARCEL NUMBER(w ELL SPTE) ���
ow
SF:(Y(M):\Y PAR ELNU BER(S WE PRIMARY'IF LOCATED ON SAME PARCEL) n n n )(n
\SATFR SOURCE SOURCE'IAPE PARCEL I LOT SUE(no minimum) PARCEL 2 LOTS%Bind m
New existing XWclI Spring ftc, y 4_
PROPOSED WATER SYSTEM NAME(REOI HIED).
VIZ,, 41 it WS f j "
I'ROOJEE('I1�DEESSCRIIPTIIIOONN(e.g.,detached AlAl l.new single-ffamily re e,esisting connection.etc.)
DIRECTIONS TO SITE/CONDITIONS/GATE CODE./EEY.LOC.ATION/ETC.
CO Ge P-D TO e�LI c 2i0 e� s(_s r n ro arc c(f.
1
if 0wSL Vsj (I ) - I so S& cisrert_ iveYrnovr.3 cAf.
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.)
fe6 p fr t'T —
Required Submittals Checklist:(additional information located on the first page of this packet)
r_<f`'Satisfactory bacteriological test from within the last year
2'Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day
EK otice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
hE 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 1 of 2
, •
---- -------------------------------- Staff Use Only ------- ------- -------- —
Review Step 1: Well Site Inspection:
YES NO N/O / ..%- `I ci.
rir ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings; indicate distance on plot plan)
❑ J`�' ❑ 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)
❑ 0 Does the ground slope away from the water source site?
lit y J 0 ❑ Satisfactory well cap?
71 ❑ ❑ Well cap screened and vented? g••
/
❑ The well casing extends �p above level : •and concrete slab?(circle one)
❑ ❑ Well tag attached to well casing? Lat: lat6 tO6
CI IDEvidence of an adequate surface seal? Lon: —ft j.O$ J.
❑ Oir ❑ Variance necessary for well site approval? Tag: upfl?SI
Comments:
Pass ID Fail Inspector v
_ Date 7/f f Zo?3
Review Step 2: Two-Party Review:
YES NO NA g�l �l WL C_ �OG l�Git,5I cb I /lilt
El Water well report(well log):Date Completed Driller 04019
�tl El Satisfactory capacity test showing a/minimum of 800 GPD with full recovery to static level within 24 hours?
ul 4 • Capacity test information: Date (0( 6(MZ5 Driller/Pump Installer MOe' ft/t101g
GPM (7_ Duration(minutes) 1 70 Total Gal I 1 lO Recovery Time(minutes)to Static 3
II tO'l @ 7:; ❑ Satisfactory bacteriological analysis? Date Wf( /N Testing Lab VrAtfy van( 1Q6s OI P(k
❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z 13o6 [ "
ik
❑ ❑ The system appears adequate to serve two connections based on the information provi4? / rz
Comments:
(Van SI:ketiVed Capau` kV- if Se- b4-'T OCT
c -a, ?��5
Approved ❑ Denied Reviewer 19\ Date W r �„
(),A '�ENT4/11
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express Ef L7/
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:07/23/2025
This form may be scanned and made available for public viewing on the Mason County website.
Page 2 of 2
r
/ co < i s- �2 M 6 J tA)). L -4l,
WATER WELL REPORT DEPARTMENT OF NoticeoflntentNo. WE49709
ECOLOGY Unique Ecology Well ID Tag No. BNH 769 .
Type of Work State of Washington L!�
0 Construction Site Well Name(if more than one well): UZf
❑ Decommission b Original installation NOI No. Water Right Permit/Certificate No. SEP n Proposed Use: 0 Domestic 0 Industrial 0 Municipal Property Owner Name Dan Hess 4 Z025
❑Dewatering ❑irrigation 0 Test Well 0 Other Well Street Address 0 SE Ellis Rd,Lot 2 RP
CF/VED
Construction Type: Method:
E New well 0 Alteration 0 Driven O Jetted 0 Cable Tool City Shelton County Mason
0 Deepening ❑Other ❑Dug I9 Air- ❑Mud-Rotary Tax Parcel No. 31904-11-90020
Dimensions: Diameter of boring 6 in.,to 79 ft. Was a variance approved for this well? ❑Yes O No
Depth of completed well 79 ft.
Construction Details: WallIf yes,what was the variance for?
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
• 0 6 in.. +1 79 .25 in. O I ❑ D 1 ❑ Location(see instructions on page 2): Q WWM or 0 EWM
❑ I ❑ in m• ❑ 1 D D 1 ❑ NE ''A-%of the NE 'A;Section 04 Township 19N Range 03
❑ I D in. in. ❑ I D DID
❑ I 0 in. _ in. D I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.16899
Longitude(Example:-120.12345) -123.05658
Perforations: 0 Yes CI No Type of perforator used
No.of perforations_ Size of perforations in by in Drillers Log/Construction or Decommission Procedure
Perforated from ft.to ft.below ground surface nature
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: O Yes 0 No O K-Packer ) Depth 73 ft. information Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type Stainless Steel Model No.
Diameter 5 in. Slot sir .018 in from 74 ft.to 79 ft. Top soil,gravel 0 1
Diameter_ in. Slot size in.from ft.to . Sand,gravel,silt,brown/soft 1 10
Sand,gravel,silt,brown/soft 10 53
Sand/Filter pack:0 Yes O No Size of pack material in
Materials placed from ft.to ft. Sand,gravel,silt,brown/hard,wb 53 64
Sand,gravel,silt,brown/soft,wb 64 78
Surface Seal: 0 Yes ❑No To what depth? 18 R Sand,silt,wb 78 78
Material used in seal Bentonite Granular
r
Did any strata contain unusable water? 0 Yes 0 No
Type of water? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name N/A Type:
H.P._ Pump intake depth:_R Designed flow rate: gpm
Water Levels: Land-surface elevation above mean sea level E.
Stick-up of top of well casing +1 ft.above ground surface
Static water level 38 R below top of well casing Date 8/17/2022
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Tests:
Was a pumping test perbrmed? O No 0 Yes b by whom?
Yield_gpm with_ft.drawdown after_hrs.
Yield gpm with_ft.drawdown after bra.
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 bra.}
Air tut 50 gpm with stem set at 77 ft.for 1—hrs. Date 8/17/2022
Artesian flow_gpm
Temperature of watt _'F Was a chemical analysis made? O Yes O No Start Date 8/16/2022 Completed Date 8/17/2022
WELL CONSTRUCTION CERTIFICATION: I 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.
Oa Driller 0 Trainee 0 PE—Print Name Chris Jones Drilling Company Moerke&Sons Pump and Drilling
Signature C'A..: cT--.h. Address 1162 NW State Avenue
License No. 2253 City,State,Zip Chehalis,WA 98532
IF TRAINEE:Sponsor's License No.
Contractor's
Sponsor's Signature Registration No. MOERKSP072N5 Date 8/17/2022
ECY 05 I- (Rev 11/18) if u need this document in an alternate forma;please call the Water Resources Program at
Pri me d F petit as `1 1�yitltn n Relay Service. Persons with a speech disability can call
Printed from Mason County DMS
MOERKE & SONS PUMP & DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805
PUMP TEST
DAN HESS - HESS LAND & HOMES 1 /
18623 ELDERBERRY ST SW /pi ., -, ; ,!;'r,,, ;ROCHESTER, WA 98579
t:
WELL SITE ADDRESS: 150 SE SISTER MEADOWS LN, SHELTON WA 106
Pump Make & Model: 1 HP Pump Set At: By w
•
Sounder Make & Model:
Make & Model: Measured in: GALLONS _,
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES
0 215816 31'
1 14 215830 32'
2 14 215844 33'
3 13 215857 35'
4 12 215869 36'
5 12 215881 36'
6 12 215893 36'
7 12 215905 36'
8 12 215917 36'
9 12 215929 36'
10 12 215941 36'
15 12 216001 36'
20 12 216061 36'
25 12 216121 36'
30 12 216181 36'
35 12 216241 36'
40 12 216301 36'
45 12 216361 36' ,
50 12 216421 36'
55 12 216481 36'
60 12 216541 36'
90 12 216901 36'
120 12 217261 36
RECOVERY
0 36'
1 34'
2 32`
3 31'
SIGNATUR •
NS PUMP AND DRILLING
9
d
4
0
•
vanguard Laboratory
� r ram- r '`—
�! 2635 Parkmont Lane SW,Suite A
Olympia WA 98502 j Ego::
' f, fir:s.`;�
V ��RSP -- --- 360-967-7010 �! Q
GN021/F04 COLIFORM BACTERIA ANALYSIS FORM z5
Dale Sample Collected Time Sample County By
Collected
10 I 1 ZS 2 ,3p Arm MY'1Sori
lacoh Day Yeu
Type of Water System(check only one box)
❑Group A ❑Group B tit Other- 2 'l
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IO7E ._ ._
System Name: ni>rti,4 tiiess
Contact Person: Ayat>,noA-kt ___ •
Day Phone:(Sub )-14 >-3eC5 Cell Phone:( )
Email: Eve.Phone:( )
Send results lo:(Print fill name.address and Sp code or e-mae)
_Motratrk_ * tSnr4S-
__Itu2 raw $rvct . +9'sC --
' CN> tntnus kr.pA g8632
SAMPLE INFORMATION
Sample collected by(name):
Specific location where sample collected: Special instructions or comments:
0 \05\6110.-
15p SE SiS t t✓.e L4thf "� W O t (-Mate
144. $hE Ifot4 tan
Type of Sample(select only one type of sample from types t through 5 below)
1. Routine Distribution Sample(AP) 2.❑ Repeat Sample(NP)
Chlorinated:Yes No (from distnbution system after unsal routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect dale:
Si I 1 /
Chlorinated:Yes Na
❑Triggered(NP) Chlorine Residual:Total Free
❑Assessment (A/P)
4. Surface or GWI Raw Source Water Sample(Enumeration) S f
❑E.cols ❑Fecal Fdle,ei Yes Ito__
5.0 Sample Colecled for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coe(orrn Present and l Satisfactory
❑E.coBpresent ❑Ecoli absent
Bacterial Density Results:Total Cotiform 1100m1 E.co&L__ /100m1.
Fecal CoRlorm /100en1, NPC 11 ml.
• Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume El Damaged Container ❑
lab Reference Number
Rapt Te ': Method Code: SM9223B
Date Repared to DOH Lab Use Only.
DON LabSzrnplef
285- (Vj --'307)
Air
fir_
• 2230642 MASON CO WA
09/12/2025 10 04 AM NOTCE
HESS. OANIEL *213970 Rec Fee $304 50 Pages 2
IIIIIIIIIIIIIIIIIi1IIIIIIIINHIIIIIIIIIIIIIfillIH IIIINIIIIIIII
Return 10
1S?r,.Z'� �neJxtc ► S1 S`^l
Grantor(s): (1) L r sir- OP$tAJ J J 1 Zj 4A-, (2)
Grantee(s):(I)PUBLIC
Legal Description(I) /Y& e SO L -r i ° as
(Abbreviated form:i.e. lot, block,plat or section,township,range)
Assessor's Tax Parcel:(1) 3 1 (10 tf — 61 0 0 74
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) 3 I 'Q 1 t r 0') 2O
Tax Parcel:(Connection 2) IA 610 q- t i - q 60
-2-0
The system owner is responsible for keeping this system in compliance.
The name of the water system is:
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 40./2 day of Sc
Signature of Grantor(s):
XC (1) ,(2)
Page 1 of 2
State of Washington
County of Mason
I.the undersigned,a Notary Public in and for the above named County and State,do hereby certify
that on this y day of S1pJe b4 . 205 ,
L�SA personally 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.
,, Pu ,�
,,� Vo(XJ tkAi b 4J
`���```�`� e� Notary Public in and for the State Washington,
At' •4000"t �-� residing at !1)CLS l —
�Z zitto
a1316
Vatte dt9 O My commission expires: � 7 ic.)0(.9(,0
s. 0a11st_,,, old �y
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RFVIStON TABIF
^ NIIMBFR DATF RFV BY DFSC
/ , N Z N O a I 7.29.25 CLA ADU VIZINA - ADU EVERGREEN
N D o 150 SE SISTER MEADOWS LN-10T#2 ebergreen
PRMITTING*CONSULTING
SHEL70N,WA.98584PHONE:(30)520-125I
EVERGREENPERMITOo GMAII.COM
PERMITTING CONSULTING