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HomeMy WebLinkAboutWEL2026-00017 - WEL Application - 7/15/2026 MASON COUNTY NBT"STREET5"ELTnN ,EST 400 BH STREE 3 S HE J-'ON EXT584 B E L E AI R:360-2754467,EXT 400 Public Health & Human Services ELMA.360-482-5269 EXT 400 FAX'.360-427-7787 07/15/2026 SMITH TIMOTHY J & MARY F PO BOX 1452 OCEAN SHORES, WA 98569 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2026-00017 607 E Inspiration Way 120303190084 The 2-party water system, Smith-Fox Water System (120303190084/120303190084), 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 I COMMUNITY SERVICES RlHamaad &slid 4PW - E m IHro'hC ,V 4edl 57� �f�pot F _I 4I5 F 6th Street.(BLdg S)—SI It WA 94"sa WEL - 000 Shell 360427-96.0x400 H liv o 36O-275A46 400❑l.na'.3@14$2-5169 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION ,PPEICAVT HONE -- ----- ---- Mo c + O 4-STREET 1,C TFa'QY GOAD %. . - U.q cLJJ4JA ui-A %rt l sill nrr RP.l_sna FLT,Cn Y,9T1Tr_]1P JUN 2 uo7 c raAso+ .� Sl.i(4.r+ wA L ARrLN:JIaFR _ EnE) /203b -31 - oo By SECDND4RV PARCELTINr9E0.(SAM A3VILLNA Vft OrATP.OO]SANEPARCEL) (ZOO — 3/ - 90099 a aE<aa,alai.,, I) aE(......m..) m 2"New Existing Dr y�Well Spring P,R P< wL'10T PROPOSED SYSTEM NAME(REQUIRED)- t-Lt�tx' cOK PROJECTm tan,daama auo.a.t crn,iy r e,a..c•iij =ron€Ii ay D�r v: Eke fth 51K See iofe o/l Sr+e Pi oa DIiECrIONS 0SITE ca.Dlnovs GATE CODE:NFV I Ounnr Err. Cr La-ft - cgiaLor Jst , Y l / l0LU2 o Is; r te\- u.— Required Submittals/Requirements Checklist: Original water well report(well log)or DoE water well report for an existing well. Well tag secured to the well casing. IV Capacity test showing 800 GPD with drawdown and recovery to static level information,as described on page one of this packet In Bacteriological test(Bac-t)results: current(within 12 months)and satisfactory. Septic Records(additional locating requirements may apply ifno septic records are on file). I'll Applicable utility casement documents. i(Filing requirement,as described on page 1 of this packet'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 V J1�'�l �� Sign: ________ Date:__________ This form may be scanned and made available for public viewing on the Mason County website Pg 2 Last Updated: 5/7/2026 Please include the following site features for each parcel served by the proposed two-party well: ❑ Parcel numbers(s) ❑ Property lines/boundaries ❑ Applicable easements with the Auditor's File Number(AFN) ❑ Roads and driveways ❑ Well location with a 100 ft radius around it ❑ Structures*Water wells shall not be located in garages,barns, storage buildings,or dwellings(WAG 173-160-171) ❑ Water lines for existing and proposed connections ❑ Septic and sewer components(tanks,primary and reserve drainflelds,transport lines) ❑ Barns,chicken coops,barns,manure piles,dog kennels,commercial gardens,compost piles ❑ Chemical Storage within 100 ft ❑ Landfills (existing or former)within 1000 ft Site Drawing 5� a}1ad This form may be scanned and made available for public viewing on the Mason County website Pg 3 Last Updated. 5/7/2026 uk N WE LZOl6 -GOOD :-5FR on 607E Tns�rrut(o✓I way ( Izo303fyoe4 furl( no lonrie( be Cohli4t-e€( to IM- two'pw+y W&I ( ,rm'fiied W,'{h -L'o-parfr weft jrrwf W EL2Ol3 -0o0Jgq or] 605E aSpagllb✓J wa y ( Iz030319u083) we((BPv34( 0Du M (o7 E r p'/a�XGn wcir f Zo3 31QCOd`I2 / r 3W Reserve IWWot sm`e I Drain Field / I 55; 3P Ea ement Rd I nmary Home 15 Dec I 7T _{____ �_— 12S F _ `_____ Proposed ADU(390 sgfl) m m N all _ 20r 1T' b Wel( VO83 33a Existing Drivewaay�for 4 vehld" jo WC1� B P�3Yt SITE PLAN 807 E Inspirafion Way Shelton WA 98584 Scale:V.50' Property Info MN:120303190034 f ZOne4- 0 3e °e Lot Sze:125sues Nit vrbrmetian and data shown am mrgerierS re!aanu o, and en dedred ban a+bNc end Meet mutes beEoed to be reFewa11tis is not a rend swvoy and is rot a replaamant for a far _ ,/all l ,t l l ih Review Step 1: Well Site Inspection: YES ,N}O� N.'O ❑ ,,,h,����el-...,,,,1//// ❑ Sources ofcontamination with in l00 ft of the well'?(septic components,chemicals,livestock,etc-) ❑--� ❑ Roads located within 100 ft of the water source?Private/County/State Distance to road{s) ❑ 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 mechanically secured or welded to the casing? N.. ❑ ❑ 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 ofequipmentis prohibited. ❑ ❑ The well casing extends ( above love oun /concrete slab. Y�- tV3 ai ❑ ❑ DoF well tag attached to the well casing? v,-,t ..i i. QS4 it ❑ ❑ Variance necessary for well site approval? " 6R passyy Kass ❑ Fail Inspector Date 2/ 7o ?( (Review Step 2: Two-Party Review: YES NO NA ❑ Water well report(well log). Date Completed {71 Driller rill rn ❑ ❑ Satisfactory capacity test show mg a minimum of 500 GPD with full reco,cry to static ar' f level" within 24 ours? Capacity test information:Date 6l9/ Dnller'Pump Installer t.u{.l (� rid ti 1 y� GPM W Duration(minutes) Total Gal Recovery Time E((minutes)to Stati ry c ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI /S ❑ ❑ Satisfactory bacteriological analysis? Date /&707ZTesting Lab UMG(!(��� • Vy z `^ ❑ ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN y ' �h ❑ ❑ Signed,notarized,and recorded water use agreement?AFN ❑ ❑ Signed,notarized, and recorded access easements)?AFN ❑ ❑ Thu system appears adequate tt serve two connections based on the information provided? -7/m/7076 - f?rt_ey4C 7- +v n 4 & p(4 - Aril/: 329 Comments: Approved ❑ Denied Reviewer Date 77K( 4 ,Jr> Findings jn;/I/ revimv reflect observed conditions as they etivted an the cat of the she Inspection. No claim is made,expran or! pled n✓/AefJ)ei arfai/err,JJxis ryntem. Well site appro vu/does not constitute waver vs tern approval Al/proposed cant!utinsto new wells are suh)eci to water adequacy requirements at time ofbu icing permit per MCC 6.68 Water usage resrricrion.c� and addinontdjees mayvppIl mall wel/s drilled der January l9°i. 2018 per ESSU 6091. This forth may be scanned and made available for public viewing on the Mason County website P g 4 Last Updated: 5/7/202( WATER WELL REPORT D`F"' NnliceafmtentNo WE62834 ECOLOGY UnicueEcolo Well[D Tag No ERK183 Type nr 'ottc .,,e n.• Canon 5aewe]l Name(if more than one roll) L ❑ Daommis;on o Odgioa msellamn NO]so. Water Right Perm iu'Ccnificale No. Pmpond Uan T Domestic 0lnaasmal 2 MWk,paE Property Droner Name Marl smith =Dewalelne _'lneaoon 0 Test\cen ❑other Wei I Street Address 607 E Inspiration Way Camrtocfion Type: Method: i »ell —Alerm,on 0Dri.en Scoed Some Tool Dry Shelton County Mason Denis Z Other ❑Dug —, -Mud-Rman Tax Parcel No. 12030-31-90084 Dimemiens: Dumrnr of bonnefi in. 0 256 ft was o variance approved for this el rl Yes [[ No Depth 0f completed ell 256 ft If yes.what was the variance for' Courtuenon Details Wall Casin5 Liner Diameter From To Thinness Steel PVC\Veldea Thread G C 6 in. o 251 25 iiiA I S — I 0 Location(see mswcnons on page 2) G WWNI or O EWNI I 0 NE %-' ofthe SW 'A',Section 30 Township 20N Range 1W ` _ G ❑ _n. _ _ n ❑ C 0 C Latitude(Example 4].12343) 47.19169 N Longitude(Example .12012345) -122.85488 W Pamradd.: ❑Yes A No Type ofperton used No prilhr's Loyfddstruen mpn or De[ m ssion Procedure of •fomiom S¢e orpennrn ons in by m. Formation:Describe by colon charutee sine of vtmal and mucture.and the kind and Perforated G;m_ft.Co_ft below ground surface asnion of rlie material m earl,layer y la peneemey rim I less. rc m oay foe each[Aurae of scree.: i.Yet ❑NC IK.Paatar C IN, 249 1 information. Lao additional sheets anoross,. Manuraowsers roams Alley Machine Works Mazaial From To type Stainless slotted Model Nn. Diameter 5_ Slot ize 010 in.Gem 261 ft to 256 n. Brown fine gravelly silty sand,loose,dry 0 5 Diameter_ Slot size in from _e to ft Brown fine to medium sand and round gravel, 5 loose,dry Sand/Filter pack:G Yes S Size of pack material 8 Materials placed from_n to ft Gra sh brown fine to medium silty sand.round 8 ravel,Bose 12 Surface Seal: IYes ❑So To what depth' 18 n d Material used in sealBenlonle chips Gray silty tavell se,saturated 12 20 Om any dour contain anumhm»vet Y=: — Brawn fine to coarsee gravelly sand,Bose,dry 20 86 Type or crier' Depth ofslnn Brown fine to coarse gravelly sand,dense,dry 86 107 Method orsealmc maia olr Gray fine to coarse sand,loose 107 183 IanuhctuszYS Name\ Type' Light brown fine to medium silty sand,loose, 183 Pump'. Ff P._ Poor a[ile deprbl_ft Designed 9ow rate spur Sarmo 205 vo Brawn fine to medium sand,some gravel,wet 205 217 weer Levers: Land-sur0ce el=valmn abeJsc mean a ll ol smdm[! 2 P. Brown fine to medium gravelly sand,heaving, 217 Sdck-up of top ofu casing 0s ft aboveground 6 waterbed 256 Scotts water ln=I 180 p be! n' p of c sing Date 6/4/26 Aeteslan pressure lbs.per pare inch Dam jtesi an water is nmlm by (cap."alie etc.) Well Tau: Was a pumping test performed' F No 0 Yes G by whom Yield gem with ft drawdawn aver bra Yield _gpm with_ft trawdown after his. Yiid _apta,with_a da»amvn anv_M. Reco en dam time-zero when pump is mvl aR-tvo¢t l evel ureas used mom well top t0 water level) Time w'aer Lc=el Time \4 aierLe'el Tune wain Lord Date afpumping lest Bailer teat min with ft.drwdowa after_hrs. I Air lest,2_epm with stem Set u 2 e 20 ft for 1 m Fa. Date 6/4/26 urn flax gpm Temperarvm ofwarcr 51 °F Wass chemical analysis rase=^ Oyes ?No Start Daft 6/4/26 Completed Dare 614126 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept esponsibiliry for construction of this well,and its compliance with all Washirgmn hell constrm1On standards Materials used and the Information reponed above are true to my best knmvledse and belief S Driller C Trainee G PE-Print Na Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No 3441 Ciry.State.ZipShelton,WA 98584 F TRAINEE Sponsors License No Contractor's Sponsors Sinature Re¢ismtion No ARCADD109BKI Dam 6/4/26 ECY 03O-1-20(Rev 09/I B) Ifyou need this docianens in an alternate torn at please call the i✓aler Resources Program or 3,ID-107-65'2 Petrans rvldWearing lass can call a"I for g'ashmgton Relay Seater. Persons wLt/t a speech driahillo can c,o/87433 6311 Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Mary Smith Well Tag#: BRK183 J 'bLb Site Address: 607 E Inspiration Way,Shelton Depth: 256' Date of Test: 619/26 Static: 180 RE�ElVE0 Pump Set: 240' TIME GPM LEVEL I RECOVERY 1 Min 7.5 180.9 I TIME I LEVEL 2 Min 7.5 181.5 1 Mm I 180 3 Min 7.5 181.5 4 Min 7.5 181.9 5 Min 10 181.9 6 Min 10 183 7 Min 10 183.1 8 Min 10 183.1 9 Min 10 183.1 10 Min 10 183.1 15 Min 10 183.1 20 Min 10 183.1 25 Min 10 183.1 30 Min 10 183.1 35 Min 10 183.1 40 Min 10 183.1 45 Min 10 183.1 50 Min 10 183.1 55 Min 10 183.1 1 Hr 10 183.1 1 Hr 5 Min 10 183.1 Total Gallons Pumped: 690 Gallons THIS PUMP SYSTEM'S PSI IS SET TO 55 Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 -rx,r, ?s1 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Co erred Mason 06/09/2026 a ow. on Y.,w ®au Tyre of Water System(dred tally one bar) 0 GrwpA ❑Group B IN Omer Group A and Group B Systems—Provide from WaterFauilite5 Inventory(WEE): IDY SyslemName: Mary Smith Contact Person:Arcadia Drilling,Inc Day Phone(360 )426-3395 Cell Phone:( Email'. Eve.Phone( SardrKulkb(Pdnl full nand aldrsss and z:p cc eor ma¶ aelaarradiaeohIngt mAND jennrcadidnl4eq coon SAMPLE INFORMATION sample collected by(name):Shad Specik dcatm where sample callecRd. Special nsh oons or cammer:6: BRK183-607 E lnspiraecn Way.Shelton Counts please Type oiSample(seleetmlyone ,peolsample fmn tyres I mrwgh 5 bSw) I.❑Routine Distribution Sample(AR) 2.❑ Repent Sample(NP) Chlcnnuted:Yes No IWm d5iudon syeren aner anal mudnet Unsabsactay rootne lab number. Chbhne Residual:Total_Free_ 3.Ground Water Rule Source Sample Unsal f , routnerolled date II IS I I Chlorinated:Yes No ❑Tapered(AP) Chlanne Residual:Total_Free_ ❑Assessment(NP) 4 Surface or GM Raw Source Water Sample(Enumeradm) $ ❑E mY ❑Fecal .._ ._ 5 5.Q Same cceea.M for Inromneon Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total CW1mm Present and 0 Satisfactory ❑Ecofpresent ❑EeoGabsent Bacterial Density Results:Total Colifarm<1.0 110 NI. Ecod<1.0 1100ml. Fecal Colilortn Ir00ml. HPC It ml. Replacement Sample Required: ❑TNTC 0 Sample ten old ❑ Sample Volume 0 Damaged Container 0 Dotson eReeeirer.6/10/2026 sob Referenc er e Numb V to 1b—z_ Recepl rempc. "sent,Cede SM9223B Dale Raponm n DOH Lab use Only DO L .Senplei 2e5- o Z� 2242962 MASON CO WA 071102©26 02 42 PM NOTCE ZENITH ;223878 Roe Fee $30450 Pages 2 Rosa., Taff II IIIIII'1111I!I Mi II1111 Iii III VIII II III IIIIIII 11111111 IIIM III VIII 7f 1 1++h N01'n S no W c SL \<..1 C mr he liar w A t8S8N � �� I I JUL t l 1021 18y_ Grantor(s): (I)_.M4.rU Srt, L , (2) Grantee(s): (1)PUBLIC Legal Description(I) Loh y e( Std $la(, 1437(p77b 30- Zo - (Abbreviatedforrnr i.e. lot,block,plat or-section, towns/up, range) Assessor's Tax Parcel:(1) 1203 b -3 I- GOngq S30 - TZG - (Z1 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(I) 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) /2O30- 3 / - loot y _ Tax Parcel: (Connection 2) The system owner is responsible for keeping this system in compliance. The name of the water system is: SM, L - 6.9 i...a.k ST 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 i f 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 i 3 day of _ 20 Z( Signature of Grantor(s): (I) (2) Page 1 of2 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 thi >s I day of / -_� 20 7�i. i\\cc S personally appeared before me,who is known to be signer of the bove instrument, and acknowledged that he(she)(they)signed it GIVEN under my hand and official seal the day and year last above written. Notary Publio in and for the Stac of Washington, residingat (7 J My commission expires- vJennifer Kelly Notary Public State of Washington ommission Number25033928 it My Commission Expires 11/08/2029 Page 2 of2