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HomeMy WebLinkAboutWEL2026-00013-TWO PARTY PRIVATE WATER SYSTEM - WEL Application, Design, Letter - 4/13/2026 415 N 6TH STREET,SHELTON,WA 98584 MASON N COUNTY SHELTONr360-427-9670,EXT400• Lq BELFAIR:.360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT400 FAX:360-427-7787 04/30/2026 Arnold, Jessicca 800 W Wynwood Dr Shelton, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2026-00013 810 W Wynwood Or 420257500270 The 2-party water system, Two-Party Well (SFR+-SFR):.K&L Farms (4202575002701420257500260), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regularwater 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 Envfronnental Health Specialist Mason County Environmental. Health D to IY�IL'3.t7O COU;I�i :l i DateReceiti is Oq ( ^ 0� COMMUNITY SERVICES AinowntR ecuwe ,J{ ReceredBy: Btid R g.Ptannin%Ecpiironmental Health Community Health 10 4.15 N.6"Street,(Bldg8)—Shelton WA98584 WEL Jp '^ Shelton:'360.427-9670x 400.Belfair..360-275.4467x400 Elma: x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE Jessicca and Tyler Arnold 06 498 6227 MAILING ADDRESS-STREET,,CLTY,STATE,ZIF 800 W Wynwood Dr Shelton,WA 98584 SMADDRESS-STREET;CrII',STATE,ZIP 3 `02 6 810 W Wynwood Dr Shelton,WA 98584 LIJ PRL�L%RYPARCEL NUMBER(WELL SITE) 420257500270 8y SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED O, R 420257500260 WATERSOURCE- SO IICETYPE PARCEL. LOTSIZE(noniinimum) PARCRL2 LOTSIZE{nominimum) New J Existing. 0 Well Spring 'j b• PROPOSED WATER SYSTEM NAME(REQUIRED). K&L Farms PROJECT DESCRIPTION(eg.,delachedADt netssingleWilly:nsklence,eusdngconnecdon,etc)' 2 party well DIRECrIONS.TO SITE/CONDITIONS/GATE CODE t KEY-LOCATION FLTC let Way towards W Delaware at.0.4 miles continue onto lake Blvd.9 mites,continue on to w cloquallum rd..3 miles,turn right on w vrynwood dr..7 miles turn left and firm left Required Submittals/Requirements Checklist: W Original water well report(well log)or,DoE water well report for an existing well. well tag secured to the well casing. Capacity test showing 800 GPD.with drawdown and recovery to static level information. Bacteriological test(Bac-t)results:current(within 12 months)and satisfactory. Septic Records(additional locating requirements inay apply if no septic records are on file). Applicable utility easement documents. Notice to Future Property Owners of a Private.Two-Party Water System,Water UseAgrceutent,and Access Easement(s)recorded with the.Mason County Auditor's Office.*Note:May be recorded after the permit has been preapproved. I own,the proposed two-party water well and have the right to grant access for a second connection. I attest that the well currently has no.more than one connection. Pr► Jessicca Arnold Sign: Date:4/13`26 This form may be scanned and made.avail/!Pg e for public viewing on the Mason County website 2 Last Updated. 1/7/2026 —___.— Staff Use Only _..:....:.i:s'^"' ....,...."..Y.,..^"'" °"..:.......—.m•.........."".."^...dr"...,.. Review Step 1: Well Site Inspection: YES NO N/O ❑ 0 Sources of contamination within 100 ftof the well?(septic components,chemicals,livestock,etc.) ❑ 7 ' ❑ Roads located within 100 ft of the water source?Private/County/State Distance to road(s) 0 0 Ground slopes away from the well? ❑ ❑ Well located'outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? ❑ Satisfactory metal or plastic well cap that is nmechanically secured or welded to the casing? ❑ 0 Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? ❑ ❑ Adequate surface;seal,filled to land surface level?*Leaving voids for future installation of equipment is prohibited. tc ❑ ❑ The well casing extends 16' above leve group /'concrete slab. � Lat: t .C ❑ DoE well tag attached to the well casing? Lon: „�2 Tag I3.y( oP ❑ ❑ Variatice necessary for well ate�t pproval? : �L Comments: z fl)?6 : l3pp1 l U tl ly ' Pass Fail Inspector Date 4� 4 Review Step 2 Two-Party Review: ,M YES NO NA ( J �} f `{' ❑ ® Water well report(well log):.Date Completed �t t Driller ` 9tt1Ett 19 ® ❑ Satisfactory capacity test showing a minimum off 800 GPD with full recovery to static.level within 4 hours? Capacity test information:Date tjDrilller/Pump installer t 1M aoid GPM I Duration(minutes)3 1 Total Gal Recovery Time(minutes)to Static ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI_______i? ❑ ❑ Satisfactory bacteriological analysis? Date ( Testing Lab t ❑ ❑ Signed,notarized,and recorded notice to future property owner ?AFN__ 37 5 ❑ ❑ Signed,notarized,and recorded water use agreement?AFN Z ❑ ❑ Signed,notarized,and recorded access•easement(s)?AFN Z2 I 4q , `x ❑ The system appears adequate to serve.two connections based oil the information provided? WI g Comments: t -? Approved ❑ Denied Reviewer Datef Findings in This review reflect observed conditi is as they existed on the day of the site inspection. No claim is made,express or iiuplied•of the f Aire success orfaihne of this system. !fell sile approval does not constitute water system approval gill proposed connections to new wells are subject to•u'ater adequacy requirements at time of building perniii perAICC 6.68. Water usage restrictions and additional fees may apply to•atl new wells drilled alter Jrniuwy 19x1,2018 per 1.•;SSB 6091. This form may be scanned and made available for public viewing on the Mason County website Pg 4 Last Updated: !/7/2026 *,s 4 CURRENT WATER WELL REPORT wat»448 or�tatl&i'�WpF KtoTap,?P''Im— *' eapr=d:ilttr Notice of N4; Unique Ecology Well ID Tag No.ALL33 c c�.1.$° alrnlsslon. x"fn;circle) GonatruetlonlDeca (" Water Right Permit No. I wi L o Decommion• Property UwnerName: KEN ARNOLD []Darn.mission,t2IUCIN�IL.1lVSTALGATlONNoJice arvW.:t�vYP1WOOD'DR►VE of Intent Number Well Street Address . Domottio p tuausttstl (�Menrcipal.. City.SHELT0N Coilnty MASON F#LOpUS6D if9Et l 1, ,. Test Well D OOIit�-- 2UD=. 4W 0�ie QDoW O Cl. Location SW�ld=l14 NP.1/4.Sac Twa it_ fypBaFwoAW en�"' owetifmae+tl>nono)__ (�AtMw/SeC tZewwerl Qrtfl00ttd1tiellQd' Medtod pB Dut: O&a'ed' Cllhivt° LRVLong'(s.„tr , T tDeg g� CtC �R° Jetted Stlll REQUIRED) Lon "Miil1Sec Qr L.angDeg g atNIPNSloNS.t�rtx ofwdl 6 iast+ts,thiltta 3 3 _fl Dc 0fcompleiadwgA 313-- — a 'Tax Parcel::No.42oz575oRz�o +CEisi7lurtWddcdAlls Viz rt t a . n Wuer to ... —„ ffl A to�_ CON PRUCTION OR DECQMIViIt>SiOPI gROC€DURE' luyttikds QLttutit+stliitd lhtt>Lftom �rlt tstgtmditreldodlad [�[jj[ VI'�, yl .�1*ota? t»fi ,sr 6/leW Of1be A>alttti in each t p fiiitt at ltffitaaa ratify for each ebti>ge of Ptrra+l8atau' ° f pm, SE, 1OIADDITIONAL SltEEfSIFNECESSARY m 6Y _---m�sdta ofpafc�. SI26ofpafg. SI[7Y SANn GllA1jEL JOHN SAN SILT BOUND BROWN GRAVEL 6 65 BROWN FINE MEDIUM SAND S aim t1t0 faoat — g. SROWNSILTYSANDYtiRAVEL. 72 Difo≥ S Ric y �6 112 pr, 8 atao .�-- BROWN SILT,GRAVEL y No St>o of giavdlpad_ ----= 112 :118 GtavaVFtlsaptirsdt it, GREEN SILT.5OME<i1fAVEL 'Malpgtiep)toedfnn fl tp 1I8 i5S: BROWN'SII.TY CLAY.GRAVEL y Quo Tow dtptb?2A: 155 155 Sntmial used a � GRAY SILTY CLAY.GRAVEL EuwomTE`cmps 168., f94 Old t am!>ssed lafed- DROWN SILTY CLAY,GRAVEL Drdffiystregtooatimmtuts6lewr dYss 1Z1N? 194, 274 Depth orattste GRAY STICKY CLAY Type Of,*, 274'- 335 GREEN STICKY CLAY 3'13 ed"Idd se s *olT SLACK PBA t1RA1tEL,SOME;AND>WA'i it;. 335 ui►rl�,r�leftae�'st WATEIi'JAV IS:JAndvo€amelattroodioveft ur�sterer ti. Static level below toytif well: .Date il3/6 Ifis ptipuua.fn .Dtd4 — 4. i w r js caot by " , .:a."` ifs "t•;a'x• .f • ..,,,,f� rag4th. T�ylp�(ttlltaD, .e�.{4ftttf►G�ANGt)q'tdfR?IN Ntr� _ �.. atut.avel 7"atna WaterLevd Time WrtaLovel T%uie. W Date ofteat hre: i.itrtivdevittltau 6Bailercast- �l,hoitt.with._-.-t Maim with a#ctalet ad 330 ft for 1 1 Mesian`flow to TcciW0fdhhtet. Was nehatdarrtsarya}stswbT❑Yes mNti, Stastodtt 1213 �i GpopleledDele 1 .�. WELL CONSTRUCTION CERTIFICATION: t constructed and/or accept responsibility for constwCtiOfl of this Well,and its notnplitvwe with all d the information reported alcove are huts to my best and belief: Washington vrelltxit)shuctQn standards. MaterialsARCADIA DRiLkXNCI INC: UriliuB,Coetptmy Dtitr C1 ,C71Yttnoe N ELSON Addras POBOX°1790• f'` tit,�lu> rrron si�.utt° gty, ,ZIp.SHEi.T0N WA 965.84 UnUci oc titoce Lice CNO.•1 State886 ,b-"dot's ARCADDI096K1` Drce:1156D6, 1f711A1HFSES, - Dri�efs tice+sstd Na pteraStdawtaat Eapiugy it an Equal OppotbbntY EioJ Ecyas4-I sot�suasl �. siiil cl C' I— i-isure. . r1 a 11rf �7 /'4 / 4tl+i l 'Y Q ttJa c- cox% y -3' Pumping Test'Data C.oilectlon Sheet Not stun ID C?wncr: Well Tag No.:- z L'4 33 ii 1)011 Source 1DJ: WRter System Name: pjv4n Well Name. Type of Test: Conducted 13 -:F Date: Q4/-=, Sintie Water hovel,us nussurcd fro reforenco point): County: +S4 47 Observation Wclls7 rV I'Vc' Well Etc�atio MSL Distance of observation well. r from ttro ed well fl : Time(t)since pumping hi tit t Pumping began WateY Drawdown Rate(Q) Time cniln) l eve1 ft (ft :f/r'2 m Comments • 6 . 74 5 t 3'3 5 /44/ ii. . , { ��.____wator_s'ystcjn egign Manual December 2009 Thurston County Environmental Health 412 Lilly Rd NE 4 Olympia,WA 98506 360 867-2631 C0LIF0RM BACTERIA ANALYSIS Dabs sartxslo Cd ctcd Tune Sampls cwatj co'lfet ( LettA L�r Yc� Type oltYaet System(cheek oni)f oreirox) ❑ Prate Houeeo11 Q Croup A ❑.GMW 0 aner' y.... � Group A ar4 Group 8 SyKi=≤rns_Provhlo from Water Far tee Inventory(WFt' Syslem Nam. APR } 6 CO:16Nt fVrsan: f cA "r=f,nat: � r tnnc�cin ro. e:( l SV41 sWapt^�It Grar .aldtos #ipc4�t�mal kti SAMPLE INFORMATION Swttpke c Cctdd by(r o): aFc 4ccat*a of Jtlress vstkro sampl,cot,,OcW: Spe6r in iru arle er ootr ntsnts Ip UJ L�y,n�c !. Typo of Sornpto(mastr3racic ony one box of k+1 thrwgh#4 9''.edi be'arwY) 1.❑Routing Dlaitrlbutlon Sample 7.Repeat Samplo(after unset.routing) cinaled:Yes 1€o Cl Disbibutaon System Chlorine Resi lual.TotbL_Free®__ ChoMaod.Yea No 3.Raw Water Source Sample Cna Res dual Total—Fioa _ ❑ —GWR(NP) �. OFecal Unsa'tis"atcnyrout?rre tab rrsvbere Q Assossrc. nt tfufl1O I O(AIP) Urr•:a5sfa ory rovt'ne cow data:. ❑other � Sample collected for information Only lovost ga T,,,.,, Coefslruc6on f Repirs _ Otlxrr ir't'u''c l LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY [)Unsatisfactory Total Co'orm Present and Satisfactory [)Ea'1pfesent G Eco absent No Colaorm doO d Replacement Sample Required: ❑Saner too old(�3O hours) ❑TNTG ❑ Bacterial Density Resuh Total Corda`onn_.�...,,,___Jt0am1. E-&-.--•-JICrra- Fecal Co xirm ,.,_1100m1 EntewnxcL. j13ui 'h-8t code:- Stf 92238 ❑s�ft22?D -Do€cad Tie Recerti ❑SM92150 ❑Enerotort t"t5- L rte( DxsrrnlTMAra' i "i Q eR F � 1�.j ' � iaur rrnt�r b) tabUa Oqr. 0 8 0 EWO 6rrc,m33 3131 tc 9 t 2237AGREE990 MASON CO W 03/17/2026 10:3.1 AN 11�III�1�11ll���III�U9IIiIIIRIII Fee liDll3lll�60 ll� Pas©s: Name and Return Address:' (6 9?Y10 L1 Wyd a/- 51/1 :1 k4 wr 4v COVERPAGE THE RECORDER WILL RELY SOLELY ON THE INFORMATI R VIVIYO11cHIS COVERPAGE FOR INDEXING PURPOSES. THE STAFF WILL NOT READ THE DOCUMENT OR VERIF tHE ACCII3CY OR COMPLETENESS OF THE INFORMATION PRO VIDED:HEREIN. Document Title(s) 1. 'Shad I.Vk1! U � -/3'cerr 2. Reference Numbers(s)o( N. Its Assigned or Released ADDITIONAL REFERENCE IYS ON PAGE Grantor(s) 2 ç . 1 (' (A ADDITIONAL GRANTORS ON PAGE Grante s) ,. ~ f ADDITIONALGRANTEESON PAGE < eg l Description(abbreviated form:Le.lot,block,plat or section,township,range,quarter/quarter) \ `. L� J y oL... -fl 2C0 u y 31L/V Il LNALLEGALisONPAGE Assessor's Property Tax Parcel/Account Number(s). `lZa2. 575270 ¶ N 23-Zfl _ i 515W Z / i Y� 2 ñ_20- ADDITIONAL PARCEL#'S ON PAGE 1 -SHARED WELL USE AGREEMENT—810&800 W Wynwood DR,Shelton WA- SHARED WELL USE A .MENT - - This Agreement is made on this fA day of M 20.k between: Owner of the Well Property: Property Address: 810 W Wynwood Dr Shelton,WA 98584 Parcel Number: 42025750.0270 "Well Owner") Owner of the Receiving Property: Property Address: 800 W WYp ood Dr- WA 98584 Shelton,Parcel Number: 4202575d 6 c—\' Y ("Receiving Property p ne \ t. Both properties ar oeated' 1 ason County,Washington. 1. Purpose The pu p05 is Xreement is to allow the Receiving Property at 800 W Wynwood rnestic water from the existing well located on the Well Pro e r at.810 Dr to o�in�ic2 p W Wrw d Dr. Well I entification and Location war well subject to this Agreement is located at 810 W Wynwood Dr, Shelton W.A. K +vell•is identified by Well Tag Number ALL339 issued by the Washington State Nepartment of Ecology. ,., v 3.Permission to Use Well The Well Owner grants permission for the Receiving Property Owner to connect to and receive water from the well for normal residential domestic use. 1/4 2237990 Page 2 of 5 03/17/20261.0:31:24 AM Mason County, WA SHARED WELL USEACREEMENT--810&800 W tit'nwood DR,Shelton WA- 4.Maintenance.Responsibility The Receiving Property Owner agrees to assume resp slbili - for all.costs related to the well itself including pump repair or replacem w casing or wellhead repairs, electrical components supplyingthe well um 1 e from the well to the receiving P pump property,waterr testing, and any other mainte ce çésiaiy to maintain operation of the well. _ Each property owner is responsible for Iir oi pressure tank,pressure switch, and internal plumbing located on their respec a perties. The Well Owner shall have no financial responsibility for maintenance or repair of the well. Lh'1 •4A. Backflow Prevention .� 1 The Receiving Property shall maintain a suitable backflow prevention device on the water line at r ropty to ensure that water or pressure does not flow back toward the WelP party he Well Owner shall have no responsibility for the installation, ]]I Ee or operation of this backflow device. 5:.E1ect ? fists The Wçwner shall provide,electricalpower used to operate the well pump. If the ter ieterinines-that water usage from the Receiving Property results in above'erage ectricity consumption associated with operation of the well, the Well Owner est reasonable reimbursement from the Receiving Property Owner.The { et�rmination of above-average usage and associated cost shall be reasonably determined by the Well Owner. 6.Access The Receiving Property Owner shall have reasonable access to the Well Property for purposes of maintaining,or repairing the well and water line.Any disturbed areas shall be restored. 2/4 2237990 Page 3 of 5 03/1712026 10:31:24 AM Mason County,WA SHARD WELL USE AGREEMENT 810&800 W Wynwood DR,Shelton WA 7.Temporary Water Shutoff for Repairs The Well.Owner.reserves the right to temporar'.y.sitt,off water service to the Receiving Property when necessary for repairs or main �iance uZ h shutoff shall not exceed seven consecutive days except where additional. ' e easonably required to complete necessary repairs, Reasonable notice,. e g"ye when practical. 8.Temporary Nature of Agreement The parties acknowledge that the Receiving Property Owner intends to install a separate well in the future.When a ne I9iista11ed and the property at 800W'Wynwood,Dr is permanently disconnec rom thewell located at 810 W Wynwood Dr,this Agreement may be ter nay'tten agreement of both parties. 9. Running'With, e Lan This AgreemfiIii.zu1vith.the land and apply to current and future owners of both properties %ated in writing. 10. r ng hw g`regrr ent shall be governed by the laws of the State of Washington, 3/4 •1 2237990; Page 4 of 5 03/17/202610:31:24.AM Mason County, WA -SHARED WELL USE.AGREEMEN'T-810 tai 800 W Wynwood DR,Shelton WA- Well.Owner(Parcel 420257500270) Property: 810 W Wynwood Dr /�'1 Name: Signature: ~� Date: I Name: Signature: Date: 1 -2_t Receiving Property Own arceI'44257500260 Property:800 W Wyn hod' r' Name: Signature:nature: ' Date: «y n L Name: r . 4 fig Signatut . Date: If ary Acknowledgment of°'Washington `ty of 1( 1 }n this .day of MuU 202,before me personally appeared ^ , iaa� - rat and r vn�ncl , \esjcuc Are tkno to me to be the persons who executed this instrument.Kota Public Signature f!/l4Ut_JiUt!Uid'$)1 : Printed Namel `•• ?.gym: My Commission Expires: ='#-S XyoTAR� �6' pUBLLC 0): 4/4 " \ �0 'WASIU% N 2237990 Page 5 of 5 03/17/2026 10:31:24 AM Mason County, WA ' S 75Va _ H ,r' s , t _ ?felts k!�L 7� H / ---��--_. (��r {.c � �— ,. � tic , fjR� Gam"':etif rcr'3 vSct+"?��. ?mac tea-..... .......«.w«a,.— a A�" t/r ,°f ARNOLD Mason County Parcel:420257500260 // ocO Scale:1"=80' Sr` /\/ t March 6,2022 I / 111 �%f,.'f O�. }to �� '� � � �, f'✓f cam' a r3 rna / a ! � f f l / noF ff \t t f ,, /\,/ yr its //✓ rF % f rte, dl,� - .+✓ 770 / . \ //// // ///W ' ' jf r :r7 / / , j \ r; .�`' ( ( / • 55/\ / \\\ \ \ SS 1 1 d�/<\ çf � . /'`x ,v 1028 1" / lf �ti l\ \ rc�:r«Ir1TFliJAlx:J�I7!�,a�,'� ``t��( �Tn ,f/ 4 S/ Sflrtf jj Siff". Vti1S_U15 L'tiflY �'+J!J fI$w � � Y a�C1Y•'�i°:` �'"��`\`E$ '+ SifrO F9 1 ``' ��..��((''� riv am ing D,r Lions tr ahalton \\ \ / � d '• �[;..,, ��. J?7 by t ftfl � ,� �� �� ��tit rlcttl3 GLt sad southoast on S t?t`onaer Way ;' ,. [ tl ul tow gd Dalawar4 t 'G // Cantirtue onto_La e 3iy 1 ' L+� ry/ 135' 011E ►� ��t �rttr�ue..ontc�1N C1P4uaJlucl1..�d. `, � \\ Turn.right otlto W Wynwoad.Or t ar { !S ®a.�dlnatas Strer�t �t1 ahtcldr_4?1. 3 N'. t,p aElu 123.:1.2,7