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HomeMy WebLinkAboutWEL2025-00115 2 PARTY - WEL Application, Design, Letter - 1/7/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 1 t�. BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 01/07/2026 JOHNSON ET UX TROY 200 E Miracle Heights Dr SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00115 200 E Miracle Heights Dr 421233300000 The 2-party water system, Two-Party Well (SFR+ADU): Roam Well (421233300000/421233300000), 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, vid Anderson Environmental Health Specialist Mason County Environmental Health 1 V , MASON COUNTY Date Received: i'Yo COMMUNITY SERVICES Amount Received, la/ \�� Received By '/A 't Building, Environmental Health,Community Health S'� ) 'Hoy,00 / U Q/ 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 WEL -( .)_5- C)i ( 16 Shelton: 360-427-9670 x400 Belton::360-275-4467 x400 Elma:360-482-5269 x400 �/ TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT (i PHONE)(i D N ti440 , °t1 c� MAILING AADDDR SS- EET,CITY,STATE,ZIP \ SITE ADDRESS-STREET,CJTY,STATE,ZIP " fh- IllEtEtti j1 PRIMARY PARCEL NUMBER(WELL SITE) 1-1-14 '-'3 O066 v DEC () 9 2825 SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL)6a-in I WATER SOURCE SOURCE TYPE PARCPL 1 LOT SIZE(n n wim) L (no minimum) ❑New xistin ell ❑ S rin g � p g L—CI 4LCA.C.d PROPOSED WATER SYSTEM NAME(REQUIRED). \Da rn PA PROJE DESCRIPTION(e.g.,detached ADU,new single-fa ily residence,existing connection,etc.) 61-11#45L4/44111 r DIRECT ONS TO SITE/CONDITIONS/GATE COD /KEY LOCATION/ETC. 1-C _ z 11-Alt-t-ArtkeAltyi 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.) Oji‘jrt9 Vl/1/41 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 ili Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office Ne 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: NO N/O — Shop (i0 ff /ff .❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) ❑ `/ ` ❑ 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? ❑ ❑ Well cap screened and vented? ❑ The well casing extends / T above level y'ou 1 I concrete slab?(circle one) ❑ ❑ Well tag attached to well casing? Lat: kt 28PP)cyi ❑ ❑ Evidence of an adequate surface seal? Lon: —Ili.it Ply ❑ ❑ Variance necessary for well site approval? Tag: prr l/ $' '' Comments: Pass ❑ Fail Inspector Date ?/ '7/?c)?i2. — 1 Review Step 2: Two-Party Review: YES NO NA p log): p 06(a q/ l�Driller &cox k Ori(frii 3t ❑ ❑ Water well report(well Date Completed 1 . ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level with'i 24 hours? Capacity test information:Date 005(2015 Driller/Pump Installer I a a pm'', _Inc GPM 46.5 Duration(minutes) Z Z Total Gal TOOT 5 Recovery Time(minutes)to Static 2 Z, N ❑ ❑ Satisfactory bacteriological analysis? Date (1( 10I5Testing Lab (6vo'Fdr7 i 4f y404 Or ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN 4a 3 cf S y t I' ❑ ❑ The system appears adequate to serve two connections based on the information pro ®? lib:bp J4 Comments: H�D��ry ���?O Rect.r'v�e� CUv�(,yr y G/i 6 ��ipo4, �6' pifApproved ❑ Denied Reviewer Date / / 7/ze �NT944, 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 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 RECEIVED MAY 2 3. 2024 WATER WELL REPORT �'.. -31 DEPARTMENT OF Notice of Intent No. WE47518 WA State Department t l ECOLOGY of Ecology (t€ RO Unique Ecology Well ID Tag No. BNV877 �� l Type of Work: State of Washington El.Construction .Site Well Name(if more than one well):. ❑ Decommission b Original installation NOi No. Water Right Pcrrnit/Cediltiate No. Proposed Use: n Domestic O Industrial ❑Municipal Property Owner Name Troy Johnson O Dewateting O Irrigation O Test Well O Other ' Well Street Address 200 E Miracle Heights Dr.. Construction Type: Method: El New Well O Alteration O Driven O Jetted O Cable Tool City Shelton County Mason ❑Deepening O Other O Dug El Air- O Mud-Rotary Tax Parcel No. 42123-33-00000 .. • Dimensions: Diameter of borin 6 in.;to'240 ft. Depth ofcomplet d Well 235 Was a variance approved for this well? O Yes QNo Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread al I Ei 6 in. 0 235 -025 in. DI I O O I ❑ Location(see instructions on page 2): C3 W\VM or O EWM E. I ❑ in. - in. O I ❑ ❑ I ❑ SW %-'/.of the SVV '/r,Section 23 Township 21N Range 4W Oil ❑ in. •in. ❑ I ❑ ❑ I ❑ • Clio in. in. O I O 0 I ❑ Latitude(Example:47.12345) 47.287949 N Longitude(Example:-120.12345) -123.161942 W Perforations: ❑Yes ©No Type of perforator used No.of-perforations_ Size of perforations in.by in. Driller's Log/Coostruction or Decommission Prod dare Perforated from ft.to_R below Bound surface Formation:Describe by color,character,size of material and structure,end the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: O Yes El No ❑lc-Packer Depth_ft information. Use'additional sheets if necessary. L 8. Ma nufacturef s Name L Material From To Type Model No. Diameter_ Slot size in.from _R.to_ft. Brown fine to medium sandy gravel,loose,dry 0 46 _ Diameter_ Slot size_in.Rom _It to_O. Broom fine to medium sand gravel,silt bound, 46 _ tight,dry 129 5 Sand/Filter pack:O Yes 0 No Size drink n;aierial in. Gray clay,stiff,dry 129 140' `; Materials placed from ft to_ft — Surface Scat: (]Yes O No To what depth? i9 ft. Black sharp gravelly gray clay,stiff,dry 140 144 Material used in seal Bentonite Chips Brown fine to medium sandy gravel,brownish 144 Did any strata contain unusable water? O Yes O gray silt,binding,tight,dry No - 171 s Type of water? Depth of strata Brown fine sandy gravel,brown clay,binding 171 Method of sealing strata off with organics,tight,dry 179 Brown medium to coarse sandy gravel,tight,wet 179 183 Pump:Manufacturer's Name Type: Gray silty clay,stiff,dry .183 185 u H.P._ Pump intake depth:_ft. Designed flow rate: gpm Brown fine to medium sandy gravel,sharp, 185 Water Lects Land aurfac elevation aboe mean sea teel '267 R. tight,dry 191 5 stick,up of top of well cuing 1_5 R.above ground surface Gray.Clay,stiff,dry 191 210 s Static water level 162 ft below top of well casing Date 6/9122 Artesian pressure_lbs.per square inch Date Brown fine sandy gravel,tight,sharp,dry .210 223 . i Artesian water is controlled by (cap-valve,etc) Gray clay with black sharp gravel,hard,dry 223 227 n Brown coarse sandy gravel,tight,water 227 236 a Well Test: Gray clay,hard,dry 236 238 Was a primping test performed? O N '❑Yes by whom? • Yield gpm With_R.dra edown offer_hrs. Black sharp gravel,gray silt bound 238 240' $ Yield gpm with;_ft drawdown oiler.-. hrs. a' Yield_gpm with_ft.drawdown alter._hrs. u Recovery data(time=zero when pump is turned off—water level measured from well S top to water level) — Time Water Level Time Water Level Time Water Level — • u — Date of pumping test Bailer test gpm with_ft.drawdosvri after hrs. ., . Air test 30 gpm With stem set at 22 ft.for r1__hrs. Date 6/9/22 — Artesian flow_gpm Temperature of['cater 5:?.._:'F Was aChemical analysis made? ❑Yes El No Start Date 6/8/22 Completed Date 6/9122 WELL,cONSTRUCfION CERTIFICATION: ['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. ID Driller O Trainee O PE—Pr ttl ' e Roger Phythlan- Drilling Company Arcadia Drilling Inc. -Signature "-~ _ . Address PO Box 1790 • :License No.2053 f/ City,State,Zip Shelton,WA 98584 • IF TRAINEE:Sponsor's Cic(nse No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1, Date 6/9/22 ECY 050-1,-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360,407-68,72; Persons tritl,hearing loss can call 711 for Wa.eliingfon Relay Ser ice. Persons with a speech disability can call 877.833-6311. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Troy Johnson Well Tag#: BNV877 Site Address: 200 E Miracle Heights Dr, Shelton Depth: 235' Date of Test: 12/03/2025 Static: 162' Pump Set: 200' TIME GPM LEVEL RECOVERY 1 Min 167 16.5 TIME LEVEL 2 Min 170.8 16.5 1 Min 175 3 Min 172.5 16.5 2 Min 172 4 Min 174 16.5 3 Min 171 5 Min 175 16.5 4 Min 169.8 6 Min 176 16.5 5 Min 168.5 7 Min 176.9 16.5 6 Min 167.5 8 Min 177.5 16.5 7 Min 167 9 Min 177.9 16.5 8 Min 166.5 10 Min 178.2 16.5 9 Min 166 15 Min 180 16.5 10 Min 165.5 20 Min 181.5 16.5 11 Min 165 25 Min 182 16.5 12 Min 164.5 30 Min 182.1 16.5 13 Min 164 35 Min 182.2 16.5 14 Min 163.5 40 Min 183.3 16.5 15 Min 163 45 Min 182.4 16.5 16 Min 162.7 50 Min 182.5 16.5 17 Min 162.5 55 Min 182.6 16.5 18 Min 162.4 19 Min 162.3 Total Gallons Pumped: 907.5 20 Min 162.2 21 Min 162.1 22 Min 162 D 2234542 MASON CO WA 12/1212025 10:40 AM NOTCE TROY JOHNSON #217094 Rec Fee $304.50 Pages: 2 I!11011 IHHIll III III II ItI II IIIIII III IIII IIII IIIII IIIIM III IIII I ff111 I11I IIII IIII Return To johliseivi 00 . I G 1C/ Iii. D _ �q�v 4. 2.4c.1 1Gq� 0x40 7..,:)) ---' -‘\‘N\OC\ Grantor(s): (1) J 8 Ii ri ,(2) \\„.,_ Grantee(s):(1)PUBLIC ,� r t.. , �� _ Legal Description (1) . , ,$J vv 5-Z.3 1 T2 In/ 14 (Abbreviated form:i.e. lot,block,plat or section, township,range) Assessor's Tax Parcel: (1) -;>i1-1" 7 5-77 3 0 00 00 `�, NOTICE TO FUTURE, F,I '1}'0WNERS OF PRIVATE TWO-PARTY WATER SYSTEM I(We)the undersigned anto •s) 'miry that the water source located on the above-described real estate under Legal Descri{don(1)fi d ssessors Tax Parcel(1)situated in Mason County, State of Washington,has beep esign tdd to serve a source of water to the following parcels situated in Mason County, State o i In tp erein described: , Tax Parcel onn ctio ) - t `7• ' v 00 0 v Tax P7,1: nnpection 2) ' Z- 1 2_ 7J •�j zj () 0 00 0 They� em `' this system in compliance. .ys,�r � s responsible for keeping :amme.o$ he water system is: -o6-c 1 VV I!/U 1 ! This systtm is designed to provide for two service connections. Planning and design approvals must be N \ tJae' .5./from the department prior to expanding beyond this number of services. '4dnally, a water right,obtained from the Department of Ecology,is required if the water system eds exemption standards. cNNNN This system(has/has not)been granted one or more waivers from specific provisions of the regulations. ‘\ l Dated on this I 1:41/1 day of DC,L/(4140?-44;20 r . �// Signature of Grantor s): 11 {1) LJ ,(2) Page l of 2 P State of Washington County of Mason I,the undersigned,a Notary Public in and for the above named Co State,do hereby certify that on this 12-1VA day of 1Z-Q(,P.ArOO-1W ,2026-_ T'vxa(j .3(Snc C.(\ personally appea/bye me,who is known to be signer of the above instrument,and acknowledged that he(sh 6 y)signed it. GIVEN under my hand and official seal the day and ye. I t3 _ ritten. \•`'``uuuniaa/1� .a TA1VY /// IrjH/ /''�, orr'�' 'lie in a . for the S e of Washington, . ties r d; '.. resi i gat ,� i Com, �rsOTARp �+; s M mmission expires: A 5t (Sk-kilLnfl ♦a. PUBLIC • ; '�i�7 •2502_ ' �� 4 WAS ����`�``` /, _ /„ , , „„, Page 2 of 2 2234542 Page 2 of 2 12/12/2025 10:40:57 AM Mason County, WA 1 i I • , , I ! .,L--1-'-1.'', �it '�", I ! gi �i I i r I I c�l mill ju -_i lb ,*I 1 11I I. 1 It i . 1 I H i i I I t,--',---. i �,�, a 1 tT I ; •I I � ,•,--H-.I, i i I 6 01 -I ( j I I �' it '-•I . L f • 1 m ' �-I I.c ,E, n T } I I I j •I [ ( i i I j i E _ ,, 1 I II ; ; `- i I I •I I �; i K. , I I �� i 1 . i \ ; ; ,- ;-r- ------•----J ; 3 ! I 1 ' I ^' _ 'I. a a 1 l' d ; I ■�"! 1 �_ Cam . 44 ' I 1 I ( I f Iii �� � i ' jl ;� ' ' I t i I ! lit i Iw\ —O S `I t' I i I 1 I I_ o �. t-! 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PUMP CHAMBER ..Pi e- • BO 2 PVC TIGMTLINE(SCH70)-CRUSHPROOF SLEEVE UNDER DRIVE > ..".• ",.., ".1',W.T:ii.C.NVII, . \•, \\ 24 \'. .—.."--7.''''N.N. c 1 �--4'GRAVITY TIGHTLINE(CLEANOUTS EVERY 100E-11 \\ SCALE-1'=200'-0" \�,\ I - — iI1I1.— \ / 0-s\t.. J\ — ' \ -..:f.:::.' x 1 A ) c...,-. — 100' (^ 7- 1 $ ', _ =1320' _ i i . :RO V 1� �0V �0 wA• E MIRACLE HEIGHTS DR /! 5 2n23 c — — 1 .... ,I',,,. S H`�" L PRESSURE TEST COMP ETED BY INSTALLER 7 K�j t4' INSPECTION PORTS/LAT CLEANOUTS SQUIRT HT: 60 JIM HUNTER&ASSOC. CONTRACTOR r,a -; DRAWDOWN: 1.TS IN/MIN DETAIL#t-SCALE-1 =30'-o' P.O.BOX 162,0LY,WA 98507 TRAVIS VILLINES t 753-1226 - '' 1HANDASSOCIATCSEHOTMAILCOM INSTALL DATE- 8/28/23 II TIMER SETTINGS- RECORD DRAWING SITE ADDRESS/LEGAL ON: 1 MIN 200 E MIRACLE HEIGHTS DR OWNER• TROY JOHNSON OFF: 4:0:00 HRS . . - I) FINAL DATE- 8I30/Z3 SWG2022-00316 I: TEA SITE.a -.,. 42123-33-00000 I