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HomeMy WebLinkAboutWEL2026-00013-TWO PARTY PRIVATE WATER SYSTEM - WEL Application, Design, Letter - 4/30/2026 1 T MASON COUNTY 415 N 6TH STREET,SHELTON, ,WA 98584 • SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 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 Dr 420257500270 The 2-party water system, Two-Party Well (SFR+ SFR): K& L Farms (420257500270/420257500260), 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 MASON COUNTY Date Received: oq COMMUNITY SERVICES Amount Receive: Received By: �o k)L O� y Building,Planning,Environmental Health,Community Health 415 N.6"'Street,(Bldg 8)—Shelton,WA 98584 W E L " Shelton:360-427-9670x400 Belfair:360-275-4467x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE Jessicca and Tyler Arnold 06 498 6227 MAILING ADDRESS-STREET,CITY,STATE,ZIP 800 W Wynwood Dr Shelton, WA 98584 lr SITE ADDRESS-STREET,CITY,STATE,ZIP 1113 2026 810 W Wynwood Dr Shelton, WA 98584 PRIMARY PARCEL NUMBER(WELL SITE) 420257500270 113Y SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED O 420257500260 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE(no minimum) PARCEL 2 LOT SIZE(no minimum) New j]Existing Well Spring PROPOSED WATER SYSTEM NAME(REQUIRED). K&L Farms PROJECT DESCRIPTION(eg.,detached ADU,new single-family residence,existing connection,etc) 2 party well DIRECTIONS TO SITE/CONDITIONS/GATE CODE!KEY LOCATION!ETC ter Way towards W Delaware st.0.4 miles continue onto lake Blvd.9 miles,continue on tow cloquallum rd..3 miles,turn right on w wynwood dr..7 miles turn left and turn left Required Submittals/Requirements Checklist: _ IyJ 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 may 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 Use Agreement,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. Print: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 Review Step 1: Well Site Inspection: YES NO N/O ❑ El ❑ Sources of contamination within 100 ft of the well?(septic components,chemicals,livestock,etc.) ❑ 0 ❑ Roads located within 100 ft of the water source?Private/County/State Distance to road(s) ❑ ❑ Ground slopes away from the well? 0 ❑ Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? l�l i Zd�t of Y l "� ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? ooq fs lDo s 11 ❑ ❑ Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? ❑ El Adequate surface seal,filled to land surface level?*Leaving voids for future installation of equipment is prohibited. tr ❑ ❑ The well casing extends [I 6 above leve group /concrete slab. Lot: y( ❑ ❑ DoE well tag attached to the well casing? . (l Lon: -!2 (Z � . 66 c ll ❑ ❑ Variance necessary for well rite approval? Tag: 4L[3j Z oo"F ac- mt v S o Comments: YfZl?o76 Ap1m I' -b f ((7c/W- /11 b0 l' - Pass Fail Inspector Date -( 1 Z Y(?d?'. Review Step 2. Two-Party Review: YES NO NA ❑ O Water well report(well log):Date Completed of(/O Driller C�d! //1,+t't! 1J 9 ❑ ® Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level within 4 hours? Capacity test information:Date �Z Drilel�er/Pump Installer d VI`€4" to GPM/Duration(minutes) Total Gal I I(i' Recovery Time(minutes)to Static ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI_______ IXI ❑ ❑ Satisfactory bacteriological analysis? Date !7 Testing Lab �My ❑ El Signed,notarized, and recorded notice to future property owners?AFN 7237712) 91 ❑ ❑ Signed,notarized,and recorded water use agreement?AFN Z L 6 p 111 ❑ ❑ Signed,notarized,and recorded access easement( ) AFN easement(s)? l3 ?Efl tCl`�`t ❑ ❑ The system appears adequate to serve two connections based on the information provided? Z Za7 ' = ` -T_ f( ( coy r elf? . tL Pa , Comments: 14so, r, 3 - 2 lyF,r � ib [Approved ❑ Denied Reviewer Date Findings in this review reflect observed con diti is 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 19rr', 2018 per ESSB 6091. This form may be scanned and made available for public viewing on the Mason County website Pg 4 Last Updated: 1/7/2026 : I CURRENT fx. R WELL REPORT W207948 W drllkr Notice of Intent No. o �&ecoPy-Ecdave_"-owoar,' copy- 41 , Unique Ecology Well ID Tag No. ALL339 ., E C 0 L 0 C 1 mmission("x"in circle) Construcuction co Water Right Permit No.EXEMPT WELL Construction KEN ARNOLD o Decommission ORIGINAL INSTALLATIONNotice property Owner Name of Intent Number Well Street Address 810 W WYNWOOD DRIVE FROIg 'WD ®IJortaestio ❑1°� ❑Matnicip+l City SHELTON County MASON ❑Irtigatirr ❑Tea well 17Other ` otde Location SWl/4-1/4 NE1/4 Sec Twn20T R 4W ❑a Own 'inumbetofwoll(ifmotethanmc) LBtDeg LatMln/$eC rArddioned Medmd:❑D�ag, O Bored ❑Driven LeNLong t, e Rom IdledS� r Still RF QUMD) g Long Min/Sec DIMENSIONS: Dioneterofwal 6 jacbmdrilled 343 R Lon Deg'• of mmpletcd`4ell 343 R Tax Parcel No_420257500270 CONSCRUGTION MAUS Casing iliWalded j_ ' Dina from+2 R to 338 fL N PROCEDURE Installed: hoer installed Dian from tL to CONSTRUCTION OR DECOMMISSIO :f0 a, c ;:. r... each tL .. .. a. oti�f�t�ba GfiOiitaial andshrathtte, . .^::FO[ujMl �eYh S4atrim A t ..,.:-: :.�" ` -..��.,..... name oftlae trrttstal in ptattxsated,`�'W ens am carry ad ge of Ferforatiaot»' 'Ins 0' infonmatioa. SE ADDITIONAL SHEETS IF NECESSARY r3en Type pufofarused �� u J of in.and no.of pm ft rn__A.to it1A U°d:.:` - SIZEofpafs m.b9 IYSAND GRAVEL__ ___ ___ _ _ _6 SIL t3er>!! alZLYes ja II YDl�tm 336 a SILT BOUND BROWN GRAVEL 6 65 MiufistW mane JOHNSON 72 . ITD:. Model No. BROWN FINE MEDIUM SAND 86 S sla aim nt0 from 3a1� fL to 343 R BROWN SILTY SANDY GRAVEL Tz fh� slot size from ft to��_ 76 112 Mat BROWN SILT,GRAVEL 118 Mlten Ir+frr packed: y� No S A to to graveUsaad ft. GREEN SILT,SOME GRAVEL 112 adals placed from118 155 168 Surface Serf: BROWN SILTY CLAY,GRAVEL nnes QNo To what depth? GRAY SILTY CLAY,GRAVEL 155 Madam used in tam BENTONrfE CHIPS GRAY 194 1a No BROWN SILTY CLAY,GRAVEL 274 Did any strata contain unusable watell ❑Yon 194 > of sttate GRAY STICKY CLAY 335 Type.ofwata? GREEN STICKY CLAY 274 Method of sealing errata off BLACK PEA GRAVEL,SOME SAND,WATER 335 343 PUMP Mamdaeb=es Nona H P. (ma WATER LEVELS: d wrfix elevation above mean son level fr Static level 266 &below top of well Date 1 C M inch Daze .. .Art�uPtmure�—_--�t��e � 7.. si=**Wcaat<olted by vafie tde. newatorIesalowbdb0w5thh1d1el --.r« tS'- ..r art -�°`•F.:Cre';'.. ..ix��` "c3.,_ - .�<.,ti-...,.w':....c�->,.:,.::;�;.' tplry asjie oivhen pm;p tarried oIl)(aFler le,'d memursdjron,well il;Iu.... Trine Water Level f�,_.... 'Time WderLevel Time Waterl.evel Data of test Bader test Wain-with tL drawdowr aaa Airtest 20 SdA .with stem set at 330 S.for 1 has. Artesian flow rsP•m Data Tempaatus of water Was a ehptdwl.tulysu o"de7 1]Y6 1ZI No _ Completed Date 113/06 Start Dete 12/30!05 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards Materials d the information reported above are true to my best knowledge and belief. Company ARCADIA DRILLING INC. O!killer OEngineer OTraiaee N ELSON Drilling Address PO BOX 1790 diler/Engineerlrsahaee Signaare City,State,Z P SHELTON WA 96584 Dn71erorttafiKeliom cN0.1886 Dr e?NE& on' Drfl N L ARCADDI098KI Date!/5/06 iges Licensed No. Ilnller's swre Ecology lain Equal Opportunity Employer. F ECY 050-1-20(Rev 3fo5) A .nt d corn Mason Coniy DMS Prim ied from Mason County Di19S �Y« _ C , r6;crT , N!T -/)FQ C&1 4' - ?1g 4 $V7 Pumping Test Data Collection Sheet Water System ID: Owner: F• Well Ta No.: / LL 339 DOH Source ID: Water System Name- 2 v Well Name: xi pr TypeFDistanc f Test: Conducted B : F Date: Q'/— er Level(as measured from referencepoint): County: .-.c o,v on Wells7 'Jr Well Elevation SL : r=r- Distancef observation well(r)from pumped well (ft): 41 Time(t)since pumping Depth to , = Pumping began Water Drawdown Rate(Q) ` win Level(ft dt- i/t.2 m Comments r •6 __ iFr orr . 6 L bv$E� /' 6 6 L . , 0 c - / : 5 c . 3 /` fl20 AOO . . 1 ;50 v d 3fly L5 O5 / A /3;3 • 5 , / ,! /4/ `co I'I ru ' _—_Water System Design Manual December 2009 Page 251 County Environmental Health L:OE ly Rd NE t Olympia,WA 98506 I 360$67-2631 Tt COLIFORM BACTERIA ANALYSIS Date Sample Col'oLd 7 Time Sample County Collected Type of Water System(check only one box) O Private i-lousehold O Croup A O Group f3 �G hey_(�L _ Group n a if Group 6 Systems-Provide lie Water Faa sir a tnv ntory{14'FI):IRE Li /L7 Syst�m Ptame: APR 2 9 O26 Ccutaei Person: t, �,r r' alt.+��d Cell Phune:{ d CEIVED E-mail: §; jIA?A 1�Li%c{,ap c. "��.Frw;e:l ) gerg emus to:(Pant tali name,adrhr^a aia ipced=n[+nai a�51'csn) GU G> Yatt{ Dr ` i51 ..3j,i36A SAMPLE INFORMATION Sample coliectad by(name): T ai ` S oft localwcn or addreas whore sample collected: Spegat instructb_ns vr carnwnenY- ® 2 C'L)J(.)T Type of Sample(mu;»check only one box of+1 through#4 fated be ow) 1.O Routine Distribution Sample 2.RepealSample(after ursat.routine) Cn"osarelcd:Yes .lto El Distribulion System Chlorine ResidualToL:I_Free— Chio,iea!ed.Yes No 3.Raw Water Source Sample Ci tedna 1'Seeldest Totzl___v Floe_r O£.cdi—GWR(AIP) []Facet— -rru�?.G�iLspdtim r mei`-•1 Un.4%Isfac1ofyn utne labnember o Assessrr nt I.04tituring(NP) Ur>:eac'oy eoJGno ccL`ecl sdate: — fOtha_r / ample Collected for Information Only lnseti'ae Ctnshucfon I Repairs Crud LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY O Unsatisfactory'total Ccli`orm Presont and , Satisfactory ®Eoo<i prcmnt fl E.cc9 absent No COtitonTi detected Replacement Sample Required: [O Barr?e too old(>3C hours) O TRiTC O Bacteria)Density Results:Total Colifoirn____11GOm1• E rx L _ 1104rra1. I4 Fecal Cc fern _d9Ginl Enteroeo j J1©D mL 1lathed Code:13,51192238 CIShd 9222➢ Pate ?d Tm-R °abed I ®SI-419216D O EnterolertiB Lt_ . it 1: •I v DztaandT.rtDNa :ed +are• - D,trReprcA:Hsi ) r l *<--Z1.•:aif�A ICOr�nucleiPTSiti-cE_L•.I LabU&More' Q�II SJ iII t�'9q:es�A li�C9} • 2237990 26 1031 AGREE MASON CO WA 03117120 RM FlRNOLD, JE55ICA #219936 Nee Fee: $307.50 Pages: 5 IIIINIIIIIIII II!IIII1IIIlllli 1111 lll1Ullli1IJIIJIFII11111II F� Name and Return Address: _ c1 W yl d. SI__________ / App 29 COVERPAGE '\ ' )) 1 THE RECORDER WILL RELY SOLELY ON THE INFORMATI ROVI ti b'ON THIS COVERPAGE FOR INDEXING PURPOSES. THE STAFF WILL NOT READ THE DOCUMENT OR VERIF IHE ACC CY OR COMPLETENESS OF THE INFORMATION PROVIDED HEREIN. Document Title(s) 1. horecl_ J Ii US / l / I- 2. Reference Numbers(s Dvcum nits Assigned or Released / r1\�1 ADDITIONALREFERENCE#'5ONPAGE Grantor(s) ;' 2. L1e \ I i1i ADDITIONAL GRANTORSON PAGE Grant ') L41110!A T�\ ADDITIONAL GRANTEES ON PAGE <NN 1ëá1 Description(abbreviated form:I.e.lot,block plat orsection,township,range,quarter/quarter) .~l pSjju yoL 3 P o-q(l- 1 fl 2(o oF SU L 7 3J 0 r f 7_ _ rnONALLEGALISONPAGE Assessor's Property Tax Parcel/Account Number(s) 'Zb2 rj7 )2'7D 2.5-. - 4 G�2 31 vJ Z(c 1 o Zvi 2`� 20 1tDDI11ONAL PARCEL WS ON PAGE -SHARED WELL USE AGREEMENT—810 &800 W Wynwood DR,Shelton WA- SHARED WELL USE A. RMENT This Agreement is made on this j .3 day of } )201k between: Nj, Owner of the Well Property: Property Address: 810 W Wynwood Dr Shelton,WA 98584 Parcel Number:.420257500270 ("Well Owner") Owner of the Receiving Property: Property Address: 800 W Wynwood Dr Shelton,WA 985. 84 , Parcel Number: 42025756t - 1 (`Receiving Propertyvne , Both properties are County,County,Washington. 1. Purpose N ' The purpose o f l'iis Agreement is to allow the Receiving Property at 800 W Wynwood Dr to obirlQ estic water from the existing well located on the Well Property at 810 W WvAvd Dr. .(Well Identification and Location ZIlh-water well subject to this Agreement is located at 810 W Wynwood Dr, Shelton' liwell is identified by Well Tag Number ALL339 issued by the Washington State N .department of Ecology. / 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 03/17/2026 10:31:24 AM Mason County, WA -SHARED WELL USE AGREEMENT—810 &800 W jtynwood DR,Shelton WA- .r 4. Maintenance Responsibility The Receiving Property Owner agrees to assume res sihili for all costs related to the well itself including pump repair or replacem W casing or wellhead repairs, electrical components supplying the well pump a i Une from the well to the receiving property,water testing, and any other mainte ce. èéiary to maintain operation of the well. Each property owner is responsible for r o pressure tank, pressure switch, and internal plumbing located on their respe '' e perties. The Well Owner shall have no financial responsibility for maintenance or repair of the well. 4A. Backflow Prevention— �` The Receiving Property iine shall maintain a suitable backflow prevention device on the water line at tléiFproei to ensure that water or pressure does not flow back toward the Well the Well Owner shall have no responsibility for the I'tY P ty installation, r to anee;or operation of this backflow device. 5. Electrici -Qsts ;i ti TheWe�ll.Qwner shall provide electrical power used to operate the well pump. If the &determines that water usage from the Receiving Property results in above- a er ge electrici consumption associated with operation of the well, the Well Owner g t5' P P <nna3tegitest reasonable reimbursement from the Receiving Property Owner. The etèrtnination of above-average usage and associated cost shall be reasonably 4etermined 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 03/17/2026 10:31:24 AM Mason County, WA -SHARED WELL USE AGREEMENT-'810&800 W%ynwood DR, Shelton WA 7. Temporary Water Shutoff for Repairs t ' O The Well Owner reserves the right to temporarily slil if water service to the Receiving Property when necessary for repairs or maint��ance:,Such shutoff shall not exceed seven (7) consecutive days except where additions �ie . seasonably required to complete necessary repairs. Reasonable notice wflhie g��ewhen 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 Aell i�Installed and the property at 800 W Wynwood Dr is permanently disconnecl~e �'tlie well located at 810 WWynwood Dr, this Agreement may be ter natiby written agreement of both parties. 9. Running With 14e Lane �J This Agreem nt:sh1u≤with the land and apply to current and future owners of both propertiesgrrnated in writing. ff 10. Gerr ngLaw Thl ,ee ent shall be governed by the laws of the State of Washington. 3/4 2237990 Page 4 of 5 03/17/2026 10:31:24 AM Mason County, WA -SHARED WELL USEAGREEMENT—810&800 W Wynwood DR,Shelton WA- A Well Owner (Parcel 420257500270) Property: 810 W Wyn good Dr Name: k ,voer,t J 6 N4 Signature: Date: } Name: Signature: i Date: '/?-Zt Receiving Property Own r tU2575002fi0) Property:: 800 W W ood� P yn Name: Tkr Signature: Date: _311 /)) Name: & 'a L- 4rrul ti, Signatur .. Date: ka � knowled went tatrfWashington K eunty of t this 12L.day of t(L 202 , before me personally appeared gt /rv (irt1 1&t &nr�{t and ut-Q�n�ul , hex a..c& Ai ,64known to me to be the persons who executed this instrument. Notary Public Signature: *�����•�H M ,''��. Printed Name: l .My Commission Expires: w•o• ° TA0 Rr PUBLIC iNJ►n��s pR.4 4/4 ",/,,?FS : ``��� 2237990 Page 5 of 5 03/17/2026 10:31:24 AM Mason County, WA o , �f Cis rtry�S t :! SA fir, tt ' �, t .G r°�.p,�Tetr�u?�. �,� I a�';�,9e,•e� Er7 I,e''481 ,r �' /"! G..a .. A✓l /� dU T..�S� kf 9 4 { as 1�d+i'st sait.� r.r r cam:` lgy;.rA. l J {° f &'f'Ft u a r "FaO'' 1 CtF,+e j� a } r , ( ; t iil� �r�o nay �. —nx�csj - ` .s F I 77 a I Ik w D / / / Ci -t..�r '.,.. ELI _a�'at'3.,. s. r p ! it // `., ARNOLD ,\ Mason County ,rr I Parcel:420257500260 Scale: 1' 80, March 6,2022 o+= • l'\ �� �% ` (••`' tom••.--� 74Y• y r t ` aw.• - .\ 1071' ,,�`•, 1. _fir- ._.__ __ -v 1� •fi 1028 LU1 \I t ' 4 sue - \� �� I `, ` fj �r ' \4`•- '`•ms ESrryryi��J5,{r1UA1Ef3:J Iltl°Aldl�L`3_°A9:1.91.r181 � :. •� EJJ --\ l (� 168' Driving Directions from Shelton ! N. YG Head southeast on S Pioneer Way „ Q j `•\ ; Leg toward W Delaware St ' Street View � �'•' 4 L mi — d _� � Continue_onto Lake_Blyd rl ?o• ry"` l 14\s . �J 5': 0.9_mi ! continue onto W cji N `°` i 03rri N .` Tun right onto W-Wynwood Dr ` . 0.7 mi ` Turn left 170 \ ' a GIS Coordinates Street Front ' n Latitude 47.1933 Longitude-123 11237