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HomeMy WebLinkAboutWEL2025-00109 - WEL Application - 10/22/2025 415 N 6TH STREET,SHELTON,WA 98584 J` MASON COUNTY SHELTON:360-427- ,EXT 400 BELFAIR:360-275-44674467,EXT 400 f1; ; Public Health & Human Services ELMA:360-482-5269,EXT 400 lam I FAX:360-427-7787 10/22/2025 WYBENGA CHARLOTTE L 4464 WEST STATE ROUTE 108 SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00109 4464 W State Route 108 419273200010 The 2-party water system, Wybenga Water System (419273200010/419273200010), 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 ',, MASON COUNTY Date Received: I /G2 5 jCOMMUNITY SERVICES Amount Received Receives By. �'//i}�.{I/' Building,Planning,Environ mental Health,Community Health It 54 0 1 RAP 6-FC' l v 415 N.6'Street,(Bldg 8)—Shelton,WA 98584 WEL g0a5-- oat C) `--1 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PHONE CLo APPLICANT I +l(0 O- ly3L4 O- Q 3 7 Q MAILING ADDRESS-STREET,CITY,STATE,LIP `ilib, SITE.ADDRESS-STREET,CITY,STATE,ZIP 9y�.,i �.) SR toss sk&('ror. vol., algrgy nr.i h R 7075 J 1 PRIMAR\PARCEL NCMRER(%ELI.SI I I.) `f(ct-L?- 3-2.- OOO I O SECONDARY PARCEL NUMBER ISAME AS PRIMARY IF LOCATED ON SAME.PARCEL) By '{t91? _31_ - 000kb -- - WATERSOURCE SOURCE.TYPE (PARCEL I LOT SIZE.(no minimum) PARCEL 2 LOT SIZE(no minimum) New �xisting /Well Spring 9. 7 I /17 PROPOSED WATER SYSTEM NAME(REQUIRED). • 113 yb a...qo. Wo.:Ai r Sys-r1 PROJECT DFSCRIPTIOS(e.g.,detached%D1',nes,single-luridly residence,existing connection.etc.) DIRECTIONS TO SITE I CONDITIONS/GATE CODE/KEY LOCATION/ETC. • V S A4.Vd 1 (O 1 S►.,kk 4+ S '. 10 . `Tv r r. r• .e5 .,..•l-o S U. l Oct ..4 Co,+I Av.,-'- S4K',►,5►,a- r- r `f•0 vdi j ar4.- rig .{-. f-(o.. :c ed '- 41 oC /tia.c Site Plan: (may also be attached) r easements.etc.) boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,water lines,property Sty PTA-4-0,J•N,4, Required Submittals Checklist: (additional information located on the first page of this packet) Satisfactory bacteriological test from within the last year 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 1 of 2 0 Staff Use Only Review Step 1: Well Site Inspection: a CMMja1s%ilk Z oil 409 YES NO N/O — HCA K/.M"1``^^,''��j��00ur ^'66 E 1 ❑ 0 Evidence of existing s urces o contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) 0 06 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 0 Does the ground slope away from the water source site? 0 0 Satisfactory well cap? Li lA ❑ Well cap screened and vented? 1% 0 The well casing extends 35 above level ground/ 4 ncrete : ab?(circle one) T y 0 0 Well tag attached to well casing? Lat: yF.1011?-1 p- ❑ 0 Evidence of an adequate surface seal? Lon:"12,. Ig9Soj 0 0 Variance necessary for well site approval? Tag: oat go? Comments: , G k ( Ca 1 tZ 5 ►, Ih 1.41.0f.. l i�,Ge jvci P� of wP It k"iv wr�'� (1 1Cg1 j knotted /o/tS/tat� ( Pass Inspector Date /0/ it/'Z J Review Step 2: Two-Party Review: YES NO NA 8/B/Iyg$_ Beeiet t Pum f( pVi(1149 0 Water well report(well log):Date Completed Driller vi/A0 0 Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level within 24 hours? Capacity test'information:Date MOW" Driller/Pump Installer Lg 0/11 ✓ GPM 15.5 Duration(minutes) 176 Total Gal 16 20 Recovery Time(minutes)to Static q O Q/r / ❑ 0 Satisfactory bacteriological analysis? Date V it n esting Lab V Q a e Olr i ik. 0 0 Signed,notarized,and recorded notice to future property owners?AP ,, Zj 7 A ❑ 0 The system appears adequate to serve two connections based on the informaton r�oyided? Ve Comments: 4/4SO 012 j �� 1/,Z.yr Approved ❑ Denied Reviewer Y�;4 N ✓� F j4Z_//rq/ Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claiViAtnade, 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 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 t- rtfinal mid Fiat Copy with �'A'1'EF�Ga�1 ELL REPORT Application No. ent of Ecology i. d Copy-Owner's Copy {': rntrd Copy-Driller's Copy STATE OF WAl3HINOTON Permit No. .... is ..-_-._- ------- Y. 1O", tl 1ton, ,a (1) OWNER: Name )Berg '''V :artitH Address ,_,. ._(2) LOCATION OF WELL: County i,a4or 1i . i.see _ZI, T. 19t..R.(fit. ' Be,ding and distance from section or subdivision corner -_.- — — — — — LOG: (3) PROPOSED USE: Domestic VI Industrial D Municipal Q (.-IO-)__WELL - .._---_._ Irrigation ❑ Test Well ❑ Other ❑ rro aµoiknD elery1 bgpeout:jeitmrd lhfaekra?anal turrf mrat rt tlhanmasteerintuln'.aNdL stratum penetrated,vide at least One entry for each mange of fornatton• (4) TYPE OF WORK: `=M'nerb number of we ii - _SdATZRIAL t17t01f TO ,i(mo then one) New well Method: Out 0 0 _ _.. ' , Cable Driven D - ,. - _- -- _ • Deepened CI Shot o�, •• • Reconditioned 0 RotarYJ/ Jetted 0 i,ock • (5) DIMENSIONS: Diameter of well 6 , inches. Drilled - .3C(- - ft. Depth of completed well.. 3Q.0-- ft _ ,:. (6) CONSTRUCTION DETAILS: • //�� cc//t� Casing installed: F,..-Dtam.from __.0.....ft.to _....... Threaded 0, Welded, Perforations: Yes Q No1 Type of perforator used....___._.-.r. ., - .. SIZE of perforations...__--___..,_.._in.by _.._ to perforations from. ... . .... R.to..-.__...__.._. ft. perforations from . ..... ...ft.to..___....._.., ft. .. .. . perforations from ..ft. _ ft. -- 11410 • SCreenfi Yes❑ No-4 V�.r �' (/ � — - • amp wr Manufacturer's N --r_ ....- -- iSodel Nd,--- ` - --- -- I .Slat ? __tun sttej. ..... from .. ._...___ - i Gravel packed: Yes Q Nod Size of gravel;..__._,,...-_........ - . Gr.-vel placed from._--_...,..._.......-._..ft.to.._...-_...._____.,:__ft. ... se Surface seal: Yes No❑ ,TO what d /_..-.._1R ft. - T A - '^'.. Material used In seal_ •enLonS Le Did any strata contain unusable water/ Yes Cl No _- - Type of water/- Depth of strata _...-.._. ., ---, Method of sealing strata off-.._ _.. _..___....-.-...__.......-__.. ; • (7) PUMP: Manufacturers Name s.>y-_ r Lane-curtace elevation a(J ------- --.-_�.-._�_ (8) WATER LEVELS: above mtop sea level..,. X7 ._ 54t level t< DalOw top o[well Date ,IF '" - — t.sian pressure .. _.lbs.per square Inca Date _.. Ar -.. Artesian water is controlled by - ...._ __ -.-_-. ___�_. .____._._ (Cap,valve,etcl . _.._ (8) WELL TESTS: Drawdown is amount water level Is lowers{),7-// belowlevel atone eve -S Work alerted....__...... ... ..18_...._. ComDkt �'� Was a pump test made? Yes El No If yes,by whom?. ... •i ' Yield. ital./min.with ft.drawdown after hrs. WELL DRILLERS STATEMENT: - _"' �__��_._ .. ..___.___ ___. This well was drilled under my jurisdiction and this report -. •• - true to the best of my knowledge and beliel. [recovery data (time taken as zero when pump turned off) (water level .:: .1 to measured from well top to water level) t a rf(a l l r L3!II` . ''..i r l i l i n it .e. Tons water Laval Tons Water Laval I Time ware, Leval NAME...r-...........,... ,..R� .. -.--__ (Person.firm or corporation) (Type or print •• Date of test[�� lee tatt._.._,i,r�a1.lmin wfth._.._.35 ft drawdown after 1 hre •'� 1.tileel • Y _ Well Tagging Form DEPARTMENT Unique Ecology Well ID Tag Number: 13QC409 rr•r u �4- Use this form only if a well report is found. Attach original well report to this form. If a wall report Is not available, contact the Well Construction and Ucansing Office at NT.tgailczaellcy or 360-407-6860 to request a Weil Report for an Existing Wall form. Well Owtwrship First risme Last name Je Wyben9a Street Address W 4484 Hwy 108 car scale 2 Cods Shelton : Wa Location of Well woe Address W 4464 Hwy 108 City County Belfair Mason • %•' NW % Section - Township I Range SW 27 19N 4 0 EWM or®YUYNN(check one) Ladlude_Degrees Tex Parcel Number4 Z•i Q 4 s 41927-32-00010 Longitude Degrees Z3. 1 7 ¢:T_Q Report in NAD 83 or WIGS 84 Elevation at land surface 165 ®feet ❑meters(check one) Well Characteristics Location of Well Identification Tag On Well-Inside pumphouse 0 .3. C--z--�-•f—A-: I. _ Indicate the lecauon F.r.II_ H of the well within the Section by drawing a Ks M L l J : i dot reP►esenti g alai t ....4..,..; loatton N P O I R Section Number m Comments Certification:The Information reported above is true to the best of my knoKriedge end belief. 18)Consulbng Firm 0 Driller ❑Engineer 0 Property Owner Name Drilbog Company Lace Davis 1 Mike Davis Davis Pumps Inc! Davis Driili • Driller License Number Address of person comple*ig aria ban 0797 340 NE Davis Farm Rd Engineer License Number City,State,ZIP Belfair, Wa 98528 Sign. Dale S+gned 2-62; Davie Puna, inc. 340 911E Vcwie Tarm Rd 'delfair,`Wa 98528 (360)801-6107 oel . 7 Project 4464 W SR 108 Shelton ii) Capacity Test TAG: BQC407 : 'C /, <9�,5 . <(;0 Date 10/19/2025 Pump 3/4 hp 10gpm Well Depth 300' ii Static Water Level 27.1' Draw Down Recovery Time Water Level GPM 0 39.9 0 min 27.1 13.5 1 min 36.0 5 min 31.8 13.5 2 32.1 10 min 32.7 13.5 3 31.8 15 min 33.4 13.5 4 31.6 20 min 34 13.5 5 31.5 25 min 34.5 13.5 10 31.3 30 min 35.4 13.5 20 28.5 1 hr 37.3 13.5 30 27.4 2 hr 39.9 13.5 40 27.1 Capacity Notes: Vanguard Laboratory 2635 Parkmont Lane SW • : Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY Collected by: Davis Pump Inc Matrix Drinking Water 360-329-2699 Laboratory ID: V250808-13 Sampling Address: Date Sampled: 8/8/25 14:00 4464 WA State Rte 108 Date Received: 8/8/25 14:30 Shelton,WA 98584 Date Reported: 8/11/2025 Sample ID: 4464 WA State Rte 108 Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V250808-13 Analyst:IT Coliform,Total Negative 1 1 MPN/100 mL 1 8/8/25 16:29 E.coli Negative 1 1 MPN/100 mL 1 8/8/25 16:29 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 08/11/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Ton Johnson,Operations Manager on 08/11/2025 DF:Dilution Factor 17025s2017 f - MCL:Maximum Contaminant Level L i Ac w Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com www.vanguardlaboratory.com 1of1 1 Return To 2232376 MASON CO WA r S U\ c.v.`C STCE PRINKLE2#2015341 RecNFFee $304 50 Pages 2 y 6 �, S o I II111II!if III IIII IiiIII Mini IIII LIiii IIIII IIl1 l!1 II 11III IIII � - \'rou („ya q?)584 oc 447 F �0�s 0 Grantor(s): O 1 C,c t S k c.,\ S Q n^�`e- -- , (2) Grantee(s): (1) PUBLIC �T� w � 1-1 Legal Description(I) � 2. - 1 °t - (Abbreviated form: i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 1�Z.� 2. - 6GO1 -- 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 g 2� ' 000 O Tax Parcel: (Connection 2) L{ t c l- - 3 L-0 0 0 1 O The system owner is responsible for keeping this system inf compliance. The name of the water system is: w,1 6 e r•�J G'' C k t' t S 54t-in 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 leiWN day of 0 CI' 20 2-S Signature of Grantor(s): C(I) i d , (2) Page 1 of 2 1 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` �c day of()c4- . 20�S , S cgi f kui, 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. Notary Pubic in and for the Sta a of Washington, residing at ,s O'C U5Uf „�.„1„�.„„„ My commission expires: �� Fie b ` Q �,.G�E,L t Iw�y�•titi =tea`�;`DE 021�0 3`4L'. I 1 NOTARy PUBLIC •cy•°off c ode•?' y;1r� it}1 H Page 2 of 2 10/16/25, 12:27 PM TerraScan TaxSifter-Mason County Washington ,ice MASON COUNTY ,�� 7�LllliCnhinl TEGNNOlOG1E5 izji WASHINGTON TAXSIFTER SIMPLE SEARCH SALES SEARCH REETSIFTER COUNTY HOME PAGE CONTACT DISCLAIMER PAYMENT CART(0) Patti McLean Mason County Assessor 411 N 5TH ST Shelton, WA 98584 Assessor Treasurer Appraisal MapSifter Parcel Parcel#: 41927-32-00010 Owner Name: SPRINKLE, CRISTAL DOR Code: 11 - Residential -Single Family Addressi: 4464 W STATE ROUTE 108 Situs: 4464 W SR 108 SHELTON Address2: Map Number: City,State: SHELTON WA Status: Zip: 98584 Description: TR 1 OF SW1/4 Comment: Land - Land Land Land Code —_ Unit Type Units Land Shape Width Depth I Al N6 Acres 4.97000000 _ I -- Single Family Residence - Building 1 1 1/2 Story Finished - Sin le-famiy Residence i Total Area Year P''''t Remodel Year Quality Condition 1664 1935 1970 2.5-Fair/Average 2.5-Fair/Average Components ___ Building Data 1 I ICodc 'Description Units Percent T 108 Frame, Siding, Wood 0 _1 100% Architecture ' 208 Composition Shingle 0 !100% Bedrooms 309 Forced Air Furnace 0 100% Bathrooms If-423 Vinyl Sheet(SF or%) 0 100% Total Rooms F 601 Plumbing Fixtures(#) 6 Foundation Concrete 622 Raised Subfloor(% or SF) 0 1000/0 Garage Stalls 722 Carport, Shed Roof(SF) 693 801 Total Basement Area (SF) 1052 906 Wood Deck (SF) with Roof 432 908 Enclosed Porch (SF), Knee Walls w/ Glass 108 Miscellaneous Improvements Misc Improvemt. lImprovement Year In Size Roof F- Roof over dirt Fair Quality Area - 108.00 https://property.masoncountywa.gov/TaxSifter/AppraisalDetails.aspx?keyld=4372266&parcelNumber--41927-32-00010&typelD=1 1/2 • O \ t. • < k . :., .. , k D- > k ,, wy � D n1771 D b a 111 ; p 01 i A C. n I � t,, Z , ti yeb �{ R ) 1 ro Ill ER . %), Ld • 00 ..r Z ry ., .n Z •I N' k 'C ii w 61 iS '-8 a _ - �� W \ O Th " t • , . c) A N4 , .. . 1 .,‘, k Ic N --j k N a o b sli. 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