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HomeMy WebLinkAboutWEL2021-00025 22310-79-90801/90802 - WEL Application - 7/22/2026 MASON COUNTY N6SHSTREETSH27-96 EXT404 S BELFAIR 360-27A467.EXT 400 B .360-2]5S-4462 E%T 400 Public Health & Human Services ELMA-360-482-5269 EXT 400 FAX'.360-427.7787 07/22/2026 IMUS JASON & RAVEN 21 NE Lakeway Dr BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2021-00025 71 NE Lakeway Or 223107990801 The 2-party water system, Two-Party Well (SFR +SFR): Imus Well (223107990801/223107990802), 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 dande rson @masoncounta.gov Sincerely, David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY DateRecved COMMUNITY SERVICES R b 4�0 Wb'nq PIm„W,Envnmmental Hmlth Community HedlI' 415N.6"Sheet,(HIdg8)—Shciton,WA 98584 WEL 202/ - 000zc Shelton:360-427-9670 x400 nelfah:360.2754469 x400 Ll m4'.360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPPRONE.AT QSoo V?,Q. T l3ll0 2 to-4bg5 ADDRESS-STREET,�T,,STATIC Pa" \q a \ 1c 2 SITE ADDRESS-STREET,CITY,STATE,ZIP 2\ NE R O'PARCEL NtINH¢R 0VEILEn'q 22W3\ "1 \ S COVRARV PARCELNWIRER IEAS PRI RV Ie LOCATED nV SAIEPARCELI t2- \O1 g9 0 80 A ¢0.EOVRC¢ .100RCETYPE IARCEL II CT SIZE no n,In l,n a ml ZEfr minim In New Existing Well Spring n L.06 ncS PSOPOSKI)WATER sVST¢VI NA%W 1REpumm e . rROJECI'DVS(RIPnON leg.deu AD U,.<w,inIMannp'towmoe,mlIi ronneomn.ere{ DIurc1IONsfo SITEI CONDITIONS GATECODE/1(EY l OCAl ION ETC. Le\\ ttrOV\ v i X1Nt SfiQXt flNWW on \e�� Required Submittals/Requirements Cheeldist: is ( liginal water well report(well log)or DoE water well report for an existing well. FCF/�aFO D',Well tag secured to the well casing. ©Capacity test showing 800 GPD with diawdown and recovery to static level information. 12 Bacteriological test(Bac-t)results: current(within 12 months)and satisfactory. �,` .r L"(� p Ad 'optic Records(additional locating requirements may apply if no septic records are on file).C�1V �\^ 002t\_\�\ Applicable utility easement documents. J,`1T !�'2tS Notice to to Future Property Owners of a Private'1wo-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 prcapproved. 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:UQk), < Date. I dg 9° V This fonii may be scanned and made availabP for public viewing on the Mason County website 1/7/2026 g 2 Last Please include the following site features for each parcel served by the proposed two-party well: (2" Parcel numbers(s) GY Property lines/boundaries if' Applicable casements with the Auditor's File Number(AFN) ( fl \ t t \ AFN5 [W Roads and driveways [^" Well location with a 100 ft radius around it LaV/Structures "Water wells shall not be located in garages,barns,storage buildings,or dwellings(WAC 173-160-171) M/ Water lines for existing and proposed connections , ' Septic and sewer components(tanks,primary and reserve drainfields,transport lines)Qy Bas,chicken coops,barns,manure piles,dog kennels,commercial gardens,compost piles N I'v [� Chemical Storage within 100 ft ' k /Landfills(existing or former)within 1000 ft N �� RF Site Drawing fFp� Po�cel t223�o�ggoao2 (xlvicel # 2zalo1ggo81_. �ckek 2 C 1 �nvd� d , gecknr iF This form may be sehed and made available for public viewing on the Mason County websne Pg 3 Last Updated: 5/7/2026 Staff Use Only Review Step In Well Site Inspection: YES NO N/O ❑ [ ❑ Sources ofeontantination within 100 ft ofthe well?(septic components,chemicals,livestock,etc.) ❑ ❑ Roads located within 100 it of the water source?Privat /County/State Distance to toad(s) 0 ❑ ❑ Ground slopes away from the well? ❑ ❑ Well located outside ofgarages,barns,storage buildings,and dwellings,with at least 5 ft ofseparation? eA ❑a ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? 61 ❑ Access ports and openings sculed/scieened to prevent contamination;pressure gauge installed for artesian wells? - ❑ Adequate surface seal,tilled to land surface level?*Leaving voids for future installation of equipment is prohibited. Cot, ❑ ❑ The well casing extends, above level roan concrete slab. w6k ❑ DoE well tag attached to the well casing? Lon_-127 .97cv3 Tag 6RIt w ^ Sa o0 m ❑ ❑ Variance necessary for well site appmva? 4 F(PthV l end -- (flekM 2 Seal vn fecelr.l 0_I e! ,_ Cip. onunents: (' ss ilpector Date Revie, Sept: Iwo-Party Review: NO NA p y-' ❑ ❑ Water well report(well log):Date Completed_ L_ Driller I Dt A41' ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level will n24hours? Ca aei[(y test Date S//1/9 7/ p Orfflf'/ p �O{0 Driller/Pump Inatallcr IVI/WJIS� GPM I�.Y Duration(minuted) Total Gal O 1 Recovery Time�(nhhinutes)10 Static-_________ ❑ ❑ Signed,notarized, iol recorded rice to future owners? PSI Waters stem capable of supplyingat least 30 PSI( to each connection? r- IIt1 ❑ ❑ Satisfactory bacteriological analysis? Dare (I Tesung Lab S C ry[W�b f4t Tel property AFN_`'4(�R f J,f7zl' ❑ ❑ Signed, notarized,and recorded water use agreement?APN _ Z l ❑ ❑ Signed,notarized,and recorded access easement(s)?AFN I(, I ❑ ❑ The system ap cars adequate to serve two connections based on the information provided? ( oWo ?Otc: aicetued DoE W ff 4 ,M dorm w%Comments: _ !�(1k.i to 10 11'Ifi� nvmhey],^/9 (VP lL (VPl L Approved ❑ Denied Reviewer _ Ddi;-, / 1 ✓ ` 0"6 a Findings b this reeler' effect Bar d dtt us they sad shed Jo/NrAspYl P r 'N l ' rt.wr ode exprru ar implied e1 tAafu mre success of failure of of this section Veil site apPoval does rat constitute water )3tt :gpp I r . I All proposed connections m nerr wells me subject for ter adequacy requnerert t titre of bjutkhia9jpe/' nt➢er.MCC 668 I'mer acnge restrictions , and nddltlanalfees maY apply to all nesv wells drilled after Jarwaty 19°t 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 WATER WELL REPORT E( OI Off' Y III 'i �1 II II N P I ] MM 8J II r 1 I rn 1 Ill 1.3 C __ _. _ u 1n aN„ NE LakewayDr .. �AI . . 11 n LI. I rv_i.rl l B II'u Uct'iit Mason laael N',. 22310-19-90801 . nc ui. B I. r.. ICI _ dill velnJl.171 AA um ,nl1 'If• rlri..vell:' 1.• iAu • rinullo I• A' I H: - TI:.h,ul o..tilt ncc lnr° Lry L.mew Fro,,, ILti4n.�. 11,AA H l[n eIJ. ul - I - 6 n 166 Ii -. .1 1 arn'l •p1ec'I. . VWAI ill liVll NE mill, NW Scnnn 10 l '•r.Fll' 23N li nl 2W•I r I'I I r 1''1]50529 I 111 n'unrpl JSp 122 919 1 I'i1,', cIrn,p: I I ..I f n I1111rr 1 4( 1 1 I) ! Provriltirr Iii,, ii be' I 1 : ,. I Ir,e 1 1 .F.+I I a r 1<. 1 i I6 1 ..W II l .n .>t ',IFclsN.,l,n Jolson 1 . +I Ir______.n I I 6 i: .20 a 166 II r, 171 rl Brown dill 0 Ido G IIISaid&p Ilwalee 136 106 eFll 1 nnr p H. 5 d Jgavel wl6 e19 166 1)1 d 1 Si /t'.' 1 1 •. I o 1 a -..... ... ..... .... .... — . ... _...- _. . ._ . _ ___ __ . _J ...... 111 1 •r Pump A plr_160 0 . I t.. 12 _ rod nth: l I . •.n.n:h. : ,a Ind 11 - _. -. -_ . :1 — __---� •ul 3] M1I ..! I... — —ry —� _ -£l''li'iLji-'I. lit' ...'.'l . . . .. - - d. n I. it.:,,. J : I •In , l II {1111 1 1 c' -'>'' s U e1N201T1 t'eml IN 1130122 VA'F1.1.(OO'I Ili(TIIIN(FKIIFI(AT ION. Ionurn- 1 i.ezrr cl M1I'\ II,,ru,lhlnlciioii elilpi,ill add its•• 01: .vui(L-IIN,LeIiitlgIiiiIuull p nnanr:nnn wand rds.5lde,lal,nsd.arnd 16c 1n(omurinn rapunml.16,no rrra nu,P0111'be,Ims IcJee.rnd Gdief. I U ll J Iripiec La I' -14m1 hl1i Mke Davis ikiliiiijl unr.ins DavisDrilling > _ 1 Add c 220 NE D sFarm RJ Leclbc No. J __ _ t \ S /p6II r WA 98528 —IT IHAINHI SIx LnN — - (' r.I,,r p,rr is Si�n.r_e ___. ¢.c1wwL.n'<o.DAVISDI IIDOA p.na JAN2022 I1'S -1-2uIXe.uA ✓Ihnf _,rll, . :rrlr.r. : I r ll.n..vAl1 II'n l ranr I rrJ/n.lre./� I Irl,nmgl,. rur 11 IIn-u li:A k1'L1,1, 1 . u.,d.L u1, :bi 1. ,n..11 n))nul. Well Tagging FormDEPARTMENT OF ECOLOGY Unique Ecology Well ID Tag Number: BRK1 __ State of Washington D Use this form only if a well report is found. Attach original well report to this form. If a well report is not available, contact the Well Construction and Licensing Office at:wclot ecv.wa.gov or 360-407-6650 to request a Well Report for an Existing Well form. Well Ownership First name Last name \e ✓1f Street Address - 1 E TJ City Slate Zip Cad Location of Well Well Address t 1l City �` �r, � County t1 VVTC U�.iTh MI/J t - / I I Section I Township Range 'L Nw ,p 3 E] EWM orh WWM(check one) Latitude Degrees Tax Parcel Number 22 \O- 990Bo\ Longitude Degrees 1 22 . 6 g � I Report in NADB3 or WGS 84 I I^ l� Elevation at land surf ,ace rl (Dt Lyf feet ❑ meters(check one) Well Characteristics Location of Well Identification Tag nçç3,� 1^ 3 .\ '�`�/^\ D_f....C I6 A...I Indicate the location .... I y _.._..! E F G H of the well wi[hln the i .. Section by drawing a RECEIVED M L K r d dot representing that �l I location. Dapt of Ecology SWRO NJP o , R..I 28May26 Section Number Comments: Certification:The information reported above is true to the best of my knowledge and belief. O Consulting Firm ❑ Driller ❑ Engineer Property Owner Name 5lcte. IMUS Drilling ComPanY0�VNC Driller License Number o 1 ^-) yy�\4o� I nt As;f arson completing thio_sfor\ m Engineer License Number I 11 t lC-1 l).V Z� QQ� lure Date Signed 12-SlabVo NICHOLSON DRILLING INC. PUMP TEST DATE MaM NAME: E IMUS Y 13.2026 SITE: 171 NE E Lf1KEWAY DR NORTH TIME 71:00 AM QY BELFAIRWA98528 FcFi�F� WELL DEPTH 171 Feet WELL DIAMETER 6 liriches PUMP MAKE GRUNDFOS PUMPMODEL 10307-12 TANKMAKE TANK MODEL 120 Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate rwu, To Down gpm to Down gpm to Down gpm Water Water Water Static 129.0 0.0 40 142.8 13.6 660 0.0 1 134.7 5.7 45 142.8 13.6 12.0 720 0.0 2 137.5 6.5 50 142.8 13.8 780 0.0 3 139.7 10.7 60 142.8 13.6 12.0 840 0.0 4 740.9 11.9 70 142.8 13.6 900 0.0 5 141.6 12.6 12,0 80 0.0 960 0.0 6 142.0 13.0 90 0.0 7020 0.0 7 142.3 13.3 100 0.0 1060 0.0 8 142.5 13.5 720 0.0 1140 0.0 9 142.6 13.6 150 0.0 1200 0.0 10 142.7 13.7 12.0 180 0.0 1260 0.0 11 142.7 13.7 210 0.0 1320 0.0 12 142.7 13.7 240 0.0 1380 0.0 13 142.7 13.7 270 0.0 1440 0.0 14 142.8 13.8 300 0.0 1500 0.0 15 142.8 13.612.0 360 0.0 1560 0.0 20 142.8 138 420 0.0 1620 0.0 25 742.6 13.8 480 0.0 1680 0.0 30 142.8 13.8 12.0 540 0.0 1740 0.0 35 142.6 13.8 600 0.0 1800 0.0 RECOVERY Time Depth Draw lime Depth Drew Time Depth Draw to Down to Down to Down Water Water Water 1 136.6 7.6 17 0.0 45 0.0 2 133.2 4.2 12 0.0 50 0.0 3 131.1 2.1 13 0.0 80 0.0 4 130.1 1.1 14 0.0 70 0.0 5 129.6 0.6 15 0.0 80 0.0 6 129.3 0.3 20 0.0 90 0.0 7 129.2 0.2 25 0.0 100 0.0 8 129.1 0.1 30 0.0 120 0.0 9 129.0 0.0 35 0.0 150 0.0 10 D.0 401 0.0 180 0.0 comments: n! SIGNED BY: Christopher Chilton-Pump 5oper`risar 262]6 Twelve Trees LnNW stc.c SPECTRA Luhoratoiles Kitsup Poulsb".WA ...WFnelAp trtrCt 96370 (360)779 411! COLIFORM BACTERIA ANALYSIS FORM "V Dale Sample Collected lime Sampe County /30/202-to .201W� CBllecled y 50µ maSoY� u? ? i MnMeal, O y . S . «r R ` Type of Water System(chock only one box) // SitAEO ❑Group A ❑Coup B DS,Ddor_...... _. GmupA and Group B Systems—Prove from WalerFadiUes Invenlory'.VFI): ID System Name'.\fc`US L Vt W w\\ Contact Person'.. ..1m _ Day Phone'. CRNPhabe:(3( c 5 Emaw Send mauaso:Pn,n�JSempe) t yt1_Iz Vo rW RgCs52 . SAMPLE INFORMATION Sample mllecled by(name): rt\3 ra ,m1^C 5 cicoctienwheresample collected: s Special Inssuctions oreonlnlenb: Z\ NEwWCyC sauce 82\�UCIWh l&52 _ __ Type of Sample(check only one box) 1.❑Routine Gistsibullon Sample lNP) F 2.❑RepeatSample(AN) chlorinated:Yes 0 No[] Ihmn denbuln eyslemeear un:a.ream) ,madeado,y oudne lab number: Chlorine Residual Total_Free__ 3.Ground Walet Rule Source Sample --- Unsatisfactoryroutnecc ectdate: Ii IS ____I__I chlerinffid:Yee No_ ❑Tnggered (PIP) CM1bdne Residual'Total_Free . ❑Assessment(NP) 4 Surface or GWI Raw Source Water Sample(Enomeraoon) l S ❑ E Loll ❑Feral Fm.e rn _xo— ___ s samgecdlxmdfor mmrmationon : PiNN Rakxe ❑CmWi 5c,Wpab LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsalislaolory Total Cdilonm Present and etIsfactory ❑Ecollp' sent ❑Eco absenl � Badedal Density ReeultR:Toml Colllmm mp"11t1om1,Eml__monitOml. Fecal Coldotm_ dullOml. HPC dWlml. Replacement Sample Required: ❑TNTC- 0 Sample too oN ❑ SampleVONme ❑Damaged Container ❑ ietartlme Rø Nad ' *Z\ Leh Retire mpee�. -0L_ Receipt Temp C '� MCYNCade'6Atl]RRB' TL0IINI16M93RD pataln Uae one ..u: r. 0. enH bb-S,.r mucami dtnienemuwtiwuwltlu ale-�z2�Ql—__ —d.m Doti eea yIarrnnv.m,a Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories-Kitsap 26276 Twelve Trees Ln NW,Ste.C ...Where npcflence mou... Poulsbo,WA 98370 Phone: (360)779-5141 www.spectra-lab.com www.spectra-lab.com Spectra Labs - Kitsap, LLC (Poulsbo)received samples for Raven Imus on Thursday, April 30, 2026 at 3:10 am. Unless otherwise noted,all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 261679-0I hnus Well 21 NP Lakewazy Dr Source 04/30/2026 5:15 This report package contains laboratory sample results and any attachments lis d below. If you have any questions please call(360)779-5141 or email us at we,w.spectra-lab.com. Attachments m) RECEIVED This report is issued solely for the use of the person or company to whom it is addressed. Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the.sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 05/042026 Page I of I 2241869 MASON CO WA 06115/2026 0116 PO AGREE IMUS, RAVEN r223009 Rec Fee. $306.50 P.Aei 4 Name and Return Address: IILMAIIUIDIM IIl�l11,,vMII'ImIIII 4 J(n UYras (.3bo�2$W�Ibg5 Luc RECEIii COVERPAGE THERECORDER WILL RELY SOLELYCNTKIWORMATI PR0VD I?011mKCOVERPAGS FOR INDEXING PIINOSFS. THE SrW WILL NOT READ THE DOCUMENT OR VERI ACCU OR COMPIETENESS OF THE INFORMATION PROVIDED HEREIN. Document lifts(s) 1. wa�c�rse A�vf;�em Reference NumbNumbst$40f àUIIItS Ass!Rned or Released �r$V Q) y\ctWEI 7 *1 t.1sE[,E �2� ADD 1ONAt REFE RENCE IS ON PAGE_ Grantor(s) . N._`—//.r 1. ( ,r7 C,1 2.__________________________________________________________ADgTONAL GMMOMON PAGE_ Granli Iq <\ C4JS. ADD 1 X)kAL GMNTEES ON FADE legal DenrIption(abblev6hd roan:I.e.bl,bNLk prt ce W 6RN Eoem%q,arye,W.Mefqualm ADDITIOMALIEGALIE ON PAGE_ Assmor's Property Tax Parcel/Axount Number(s) 22z%W0,0,R 0801 2310 tgc)08t//�l- ADDm01ML PMm r3ON PAGE_ Water Use Agreement This Water Use Agreement ("Agreement") is made and entered fnt .by and between the undersigned property owners ("Parties"). The purpose of thW4greeihent is to establish the terms and conditions under which water access, use, maintena(tc'e r4�ponsibilities, and related rights are granted and exercised across the involved properties. '' 1. Water Source and Use ( .. The Parties acknowledge that the water sou((¢e (the ater System"including but not limited to wells,pumps, pipes, tanks,and associate$,it\ifras3,itt:ture—is shared or accessed in a manner requiring mutual cooperation. Each Party agretS-Fddse the Water System responsibly and in a manner that does not unreasonably interfere with another Party's lawful use. 2. Maintenance, Sanip. g,and Costs The Parties agree to share in tha[e�tsoble costs of maintaining, repairing, and replacing components of the Walef teta f hat serve more than one property. Cost-sharing percentages , may he determined b)cy4rpttelt:agment, proportional use,or equal division unless otherwise specified. All costs sociatedlith water quality sampling, testing, laboratory analysis, and any required reporting s M)-be included as part of the shared maintenance expenses. Sampling may be conducted as,Pe4ui?ed'b T'aw, lender requirements, or by mutual agreement of the Parties. Each Party agrees to o i�r tribute their share of these costs in the same manner as other maintenancQsxppUses. 3. is 14ility $ach Pan,uses the Water System at their own risk. No Party shall be liable for incidental ii terruptiiktis in service caused by necessary repairs, acts of nature, or circumstances beyond '��r asonable control. N. �.i Notice to Future Property Owners This Agreement shall run with the land and is binding upon all future owners, successors,and assigns of the properties benefiting from or burdened by the Water System. Any future property owner acquiring an interest in the affected property is deemed to have notice of this Agreement and agrees to be bound by its terms upon transfer of ownership. Future owners are encouraged to review this Agreement prior to purchase and to understand their obligations regarding water use, cost-sharing, sampling responsibilities,and easement rights. 2241869 Page 2 of 4 06115/2026 01:18:35 PM Mason County, WA Access Easement The Parties hereby grant to one another a non-exclusive/Q�scr ,ent for ingress, egress, inspection, maintenance, repair, sampling,and replacement of the t r�ystem infrastructure located on any participating property. This casement includes,therighkte access pumps, pipes,valves, tanks, electrical components, and any other equipsent nece sary for the operation of the Water System. Access shall be exercised at reasonable-timkbL and%th a manner that minimizes disruption to the property owner. Except in emergencies'i vagcce-n6ice shall be provided before entering another Party's property. 4. Term and Modification This Agreement remains in effecUUnless modified or terminated by a written document signed by all Parties or their successors,------------- ._.- -`,✓,' 5. Governing L3* This Agreement shake gored by and interpreted under the laws of the state in which the properties are logat�� 6. Signatures ' Prins (j'Well wner Pared O1 Rgo J\ Printed Name: 1_t111 . - .:�•, �;nate: y ?�,a lP Two Party Well Joiner Parcel#: 223\Ol9 0BC2 Signature: , nC Printed Name: 9(��IC-Y1\'l`(\US -y) t. 1 Date: y 3� 2Jo 2241869 Page 3 of 4 06/15/2026 01:18:35 PM Mason County, WA Notary Acknowledgment State of Washington County of V t"FP —_� On this '[J day of_ (� 202b. b 'rcfrk the undersigned Notary Public, personally appeared: PrimaryWell Owner: (�QQY�t\I g -11Y11kC I Two Party Well Joiner: 5icnn 4 n who proved to me on the basis of satisfactotyrevidertc'e to be the individuals whose names are subscribed to this instrument,and acknowledged thaythey executed the same for the purposes therein stated. -- " •••I„„•Illu,r, , IN WITNESS WHEREOF, I hereunto set my official seal. 91 IN Signature of Notary Public(___ _. .. WN0TARY "NO . -•- hinted Name of NotardpubliF � KIUSn'th¢ #1/ 6.NFoO _ iN PUBLIC M1�, OZ6 Notary Pu li in an(for tµ,c�.St9te of Washington My commission expires: "' No 444 OF yyj�gN�•a•° � Z I I 4N1ry II IIIIIY••• ) 2241869 Page 4 of 4 06/15/2026 01:18:35 PM Mason County, WA