HomeMy WebLinkAboutWEL2026-00021 - WEL Application - 6/17/2026 gtFaMASON 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 EXT400
FAX 360-427-7787
09/09/2026
FRENCH DOUGLAS G & KRISTIN L
PO BOX 54
SHELTON, WA 98584-0054
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2026-00021
1481 E Shelton Springs Rd
420122290084
The 2-party water system, Two-Party Well (Duplex): Shelton Springs 2026 Well
(420122290084/420122290084), 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
'el
David Anderson
Environmental Health Specialist
Mason County Environmental Health
MASON COUNTY .DSB.SI 0-1 G�c�d (c
COMMUNITY SERVICES
a ? ,3EnN, m.mlXl, Ce uniM1awM O .Dt.Cf 0
415 N 6th Sired.(Bldg R)—Shetton.WA 98384 WEL c)-c).-E.,
shcllon:360-427-0670 x4(X)Belfatr 360-275-4467x400 Lima 360-482-5369 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
AP?nLANT ��ri PhONE
�vewc �- 3[00 - 490 - Y93I
ul INC AuuRTSS-STREET.CU1,STATR,ZIP D $uX S L/ S It e. /{n,+ W A 9 D S 11
ADDRESS-STREELCITY.STATE.LIP S '�SITE IVPiI E. She (/ .. 5 c Spc Pd .- 1453 C Sh Sr;. 244
PRIMARY PARCEL NIMBLE OFELLSITE, / 0 ,a - 22 -- 22 - 9v o8 N
SLCONDARV?ARCEL.NL'SIPER I SAM¢AS ERnuRY IT LOCATED ON SAME RA
4Zo - ZL — 00
ATERSOEPCE WVRCE➢9E ?ARR.1.I IgTs¢E...mlrvmnmi ?ARCELILO A IeC fir-11 u11
fl New Existing Well ❑ Spring 5 m a, 1 A L
PROPOSED WATER,.S,tm NAME,REQUIRED, S-
1e1fcr 5pin4c 7078 k/
eu
PROJECT DESCRIPTION RR,aec.Ld AIM,s SSA64urns—
Dpios sn' v.A d ¢s1-
fR,-s A�� ç \ =+ Zeal S2 w,_hu (A-,t /2 fflr
well T' ?I -J1-J1 Zctto (4p*L-J y < 6ncl- & ' k o ckjvt
DIRlflIONSTO SITE)CONQITINa GATE(ObK1KEY LOCATION)FTC ft v.A N do -1.1-..s p.ociss .e r- -d h d
s
nil 4 cters mot- -2. p.>_r / +a øA a 2. 14t
nFF Sh� 7f S,� ^ s Rd
w¢( I CPn f CMasa ,t Cam . 51'L.1o26 - 0oop1 �11 JUL 2 2D26
Required Submittals/Requirements Checklist:
;
Original water well report(well log)or DoE water mce[I report ibr an existing well. By
Well tag secured to the well casing.
* Capaeil test showing a(10 UP I) with drov ,do n and recovery to static level information,as described till page one of this packet.
*Bacteriological test(Bac-t)results:current(within 12 months)and satisfactory. _
Septic Records(additional locating requirements may apply if no septic records are on file). S a z - d till do P /
Applicable utility casement documents. — See t/r.{I{3 c$ - A p /VASEn G P+b
Filing requirements.as described on page I of this packet'Note: May he recorded after the permit has been preapproved.
12.
I own the proposed two-party water well and have the right to grant access for a second connection. i attcs t that the well
currently has no more than one connection. y� "�
Print: K, fiti- F",e-.c-4- Sign: 7- — Date: 7 /2 3 J L (a
This form may be scanned and made available for public viewing on the Mason County website
Pg 2 Last Updated:6/30/2026
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
❑ Structure, *Water wells shall not he located in garages,barns,storage buildings,or dwellings(WAC 173-160-171)
❑ Water lines for existing and proposed connections
❑ Septic and sewer components(tanks,primary and reserve drainfields,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
S_Q2 fl1 AL
S � h .r` +I-e 64 W • M , M4 sws-
9?'LJ026 0000
e ,This form may be scanned and made available for public viewing on the Mason County we site
Pg 3 Last Updated:6/30/2026
Staff Use Only
Review Step I: Well Site Inspection:
YES NO Ni()
❑ ❑ Sources of contamination within 10011 ofthc well?(septic components,chemicals.Iivestock,etc.)
❑ ❑ Roads located within 100 ft of the water source?Private!County/State Distance to road(s)
❑ ❑ Ground slopes away from the well?
Ip ❑ ❑ Well located outside of garages. storage buildings,and dwellings,with at least 5 ft of separation?
II'p� ❑ ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing?
I1 ❑ ❑ Access pods 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 ofequipment is prohibited.
❑ ❑ The well casing extends I1 above level&concrete
slab. Lat 4i.2y 1012
❑ ❑ DoE ti ell tag attached to the wdl casing? Lori. -Itj-1304
Tag: APB
❑ ❑ Variance necessary for well site approval?
Comments:
® Pass ❑ Fail Inspector Date // /L✓
Review Step 2: Two-party Rev
Review:
YES NO NA /tl
❑ ❑ Water well report(well log): Date Completed 03(09/1907 /Driller 1.010M W✓r'A CO—
❑ ❑ Satisfactory capacity test showing a minimum of800 GPD with full recovery to static level within 24 hours?
Capacity test information:Date m/10?0p Driller/Pump Installer all OR1f
GPM L Duration(minutes) Jo Total Ga]__________Recovery Time(minutes)to Stali
❑ ❑ Water system capable of supplying at least30OPSI to each a connection?PSI_�ci
❑ ❑ Satisfactory bacteriological analysis? Date /(W?Oesting I.ab Al�la-
L
❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN z YS37yO
❑ ❑ Signed,notarized,and recorded seater use agreement?AFN
❑ ❑ Signed,notarized,and recorded access easement(s)?APN
I ❑ ❑ The system appears adequate to serve two connections based on the information provided?
Comments: 7/}
Approved ❑ Denied Reviewer Date !9 'G(/
Findings in this review ref/ecr oh.cerved condir ns ax they existed on the lap n/tlre si.e inspect/on. Nn claim is made,express or imp lied ofthefuture
success f 7ure of/his cycteni Well site a,Prnval does not o . 'I r ire system pproval
X/proposed connections to new wells are subject to water adequacvrequ.enienm at time ofbuilding permiyxr MCC 6.68 Water usagerestriction,
and addinonnl fees may apply to al/new wells drilled after January/9i, 2018 per ESSB 6091.
This form may be scanned and made available for public viewing on the Mason County website
Pg 4 Last Updated:6/30/2026
Please print,sign and return to the Department of Ecology
Water Well Report Current w 2 0�
.. . . Original -Enloy, R'eavy-owner,1-I eovy-driller Notice of Intent No.
'('C
r C
gn t 0ufIion/Deconana ion Unique Ecology Well ID Tag No. __A 9_3
[$Constlndion Water Right Permit No.
Decommission ORIGINAL INSTALLA LION Notice Property Owner Name m
ofln(enl Number /y !fPcI
OL ✓ d well Sir A dress O
PROPOSED USE: tDornStic ❑ Industrial ❑ Municipal
❑D<wme. ❑Imsadnn ❑Tea well ❑ome, City fIiTtt n� County �/ rr, y
Laat,bNW /<-I/al xl,/I l4 Scof� TwrL�.Q Icy too. Ly°h
,T,aY,�PE OF WORK: OwrciSnumberaf we Teal
,tort than erne)
L�.Iew.'m n R<rnI.—T Method ❑Di ❑ Bored 0 Do"en LatLon s t,r Lai Deg Lai Min/Sec
❑Deepened [aC,bt< ❑tto., ❑mlrw g( ,
DIMENSIONS: Dkme,er ora<D W rtenn,drilled n. still REQUIRED
Deem ornmpined well �n L/ Long Deg Long M/in/Sec
CONSTRUC_OON DETAILS 1I11 p Tax Parcel No. 12p1 22Z-1__681
Casing EJWeldedt �" Diam.Iron,40.m 951 (I.
Installed: 9Gn I :auN Dian.fro lb a CONSTRUCTION OR DECOMMISSION PROCEDURE
O'threaded o am from n to n.
p fo, a on: Ue[nbe by color,tl,on let ssof material and st rt.and me kind and
Perfomtlon ❑Y[s ol be malerml in eoch9 al U mpene aced.wi th alley entry for each change of
TYpe of perfora-rutd ofom imsdiaa<ollw reIL DITIONAL SHEETS IF NECESSI.RY
SIZE ofpef by hit,and 1 pcds_fmm_n.to_ft MATERIAL 1e FROM TO
Scree ❑HOI 'Pam Lucal;m
Mantl Nc an c— wrrS el No
D Slol fmm O.Ia '
Diam from ft R
Cnv.iFilerryded:rl]Yes ❑Ss oftlravcVaand
Ma,er;als placed from_________________________ft.,o a
Snrmee Ga1:: O. rv, ,n.naL m• / n. 3
Mmenal used it taut
Did any nma mn,oin unu.wbk Wain'( ❑Veer
Type ofwale(! Depth of 55n11 ep
Method of soiling umu off
PUMP: M.,nvfcw,cfa Yame
Troe: S ha'/LLA<LML H.P_
t
WATER LEVELS: Land-surfac11 elevation mea
n level n
son<levd 31-I -4 n.xmw t�nrw<n a,e��}
Ancitan prccurt IM.pa square,rcb Dale
Artesian wtlo s con,wi Ic by Cg
(cap va lye,etc.1
WELL TESTS: nnwduwnl n,wo le
vel vale lowcrcd below static level
pump mpp¢ssmde' D.dnuuD No If Yes.by wbom.
Y,eld yy,.y'alJin .wit 51'Lu E.drawdown afer — bts
Y;<IJ.gullet: n.JrawIown after hrs
Yield. eaGm:n.x'11.1 p.drawdoan after hrs.
nen.,....e.. e a r ^b.M ewalw!ewi r,,.....r.mY^rn..n f �O
wino woes,!eeiy
me warm Levd f.me Water La vet Time Wrer Level T RPM"
a u_ tart-tB
Daintiest _ w
? 2Q01
HaJurut al Jm,n with n.dnwdown after ors
;ne,___________gaumtn.wich stemset11 n.for brs b Dahi _n., C _
Artesian now ,rp.m. Da, '�:,.
Te.npermure ofwamr_,_Was a chemical anulyas made! Q� a w
gad DamJô complelea oats 0
WELL CONSTRUCTION CERTIFICATION: I constructed and/OF octopi responsibility for construction of this well,and its compliance with all
Washington well construction standards. Materials used and the information reported above are I to my best know! ge ale
Griner/Entll,wrnnincc Nane(prim) Th GT<tM..� [sir-s tit�C Di,IlL,g Company
DMeriEntlineerrtninee S;gna,urt lWr,—n �/�!N +rte AJJresr
Dnikr or trainee Licnu No. ztol—I C:ry,5ute,'LapO_
Il TRAINE . Conlrac/,yet .J
Uriller'r Llnmad No, Regia,V /1D T'L m,e
.L _AAL0 3L
(Drilhle' Lco a6Y Eq pp ^:iy Etnplss,er. ECY DS'J-L20 Rev 2103}
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Kristin French Well Tag#:ABP983
Site Address: 1481 E Shelton Springs Rd,Shelton Depth: 99'
Date of Test: 7117/26 Static:41.5'
TIME GPM LEVEL RECOVERY
1 Min 17 45 TIME LEVEL
2 Min 17 45 1 Min 41.7
3 Min 17 45.05 2 Min 41.5
4 Min 17 45.05
5 Min 17 45.05
6 Min 17 45.05
7 Min 17 45.05
8 Min 17 45.05
9 Min 17 45.05
10 Min 17 45.05
15 Min 17 45.05
20 Min 17 45.05
25 Min 17 45.05
30 Min 17 45.1
35 Min 17 45.1
40 Min 17 45.1
45Mn 17 45.1
50 Min 17 45.1
Total Gallons Pumped: 850 Gallons
This pumps system is set to 55 PSI
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
VAWOUS¢O 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dale Semple Collected rime Sample County
collmm
07/17/2026 ❑.a Mason
LnTh 0a Y.
—._Soma
Type of Water System(Aet only one box}
❑GraupA ❑Grop6 BGMer
Group A and Group B Systems-Provide from Water Faciite Inventory v Fla
ICm
System Name. Kristin French
Contect Person:Arcadia Drilling,Inc
Day Phone.1360 )426-3395 Cell Phone.(
Email Eve.Phone.!
Send en"mb.jpnnr Nll name.ardfss an zip cMeV mall)
eia ter dioOnlm corn µDlenn®te corn
SAMPLE INFORMATION
Sample coueaea by Name).Shad
Specifictrcaem where sample collected: Special instructions orcdnmenta.
Soper,.I.a,E 5Lenlon Springs Rd.Shelton Counts please
Type of Sample Iseka only ane type a sample from We 1 through 5 bow)
1.❑Routine Distribution Sample(W) 2 ❑ Repeat Sample WP)
Cdormded.Yes No tlrwm dlelnbanon system aver rival.mweel
Chmnm.Reidwl:Total Free Unsabslactoly realm lab number:
3.Ground C IWaRule Water Sour re Sample Unsaeslaetoryroutine md lledate.
II 1
CMainaad.Yes_ No
❑Triggered(AP) Chlmme Residual.Total_Free _.
❑Assessment(A)P)
4. Surface or Owl Raw Source Water Sample(Enumeati p$
❑E.co ❑Fecal No
S 0 Sample Cdlxl d Ic,nrarmatian Only:
LA B USE ONLY DRINKING WATER RESULTS IJg USE ONLY
❑unsahshctry Total Comotm Resent and ®Satisfactory
O E.mb present ❑E.ram maa4
Bacterial Density Ramada Teal Cairo<1.0 _Aomnl. Ecoti<1.0 libunl.
Fatal Camara 1100m1. NPC 11 ml.
Replacement Sample Required: ❑TNTC ❑Semple too old
O Sample Volume ❑Damaged!Container O
Dent&1imeR«et.e.7/17/2026 lee RehZ7 ynbu 17 -21
beceiplrempC: Meth Code.
Data Repoged 9 X. tab use Only
DCR taSwnwee
285--7r72-7
2245390 MASON CO WA
09/0312026 11 39 R" NOTCE
FRENCH .225796 Rec Fee $304 50 Pages 2
III II11111!MI IIF 11111 I11F 1111111!1111 iiIFl1111111111111111111 liD 1111
When Recorded Return To: �t L C�(� - c0� �
French
P.O. Box 54
Shelton, WA 98584 it
u SEP t rp)F
Grantors: (1) Douglas G French, (2) Kristin L French
SLY
Grantee(s): Public
Legal Description: LOT 4 OF SHORT PLAT NO. 2956, RECORDED MAY 27, 2003,
UNDER AUDITOR'S FILE NO. 1782516, BEING A PORTION OF THE NORTHWEST
QUARTER OF SECTION 12, TOWNSHIP 20 NORTH, RANGE 4 WEST,W.M., IN MASON
COUNTY, WASHINGTON
Assessor's Tax Parcel: 42012-22-90084
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE
TWO-PARTY WATER SYSTEM
We, the undersigned grantors, certify that the water source located on the above-
described real estate under Legal Description (1) and Assessors Tax Parcel (1), situated
in Mason County, State of Washington, has been designated to serve as a source of
water (two connections)for the following parcel situated in Mason County, State of
Washington, herein described:
Tax Parcel: (Connection 1) -42012-22-90084
Tax Parcel: (Connection 2) - 42012-22-90084
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Shelton Springs 2026 Well
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 if the
water system exceeds exemption standards.
This system has not been granted waivers from specific provisions of the regulations.
Dated on this 2 day of �P , 2026.
IN WITNESS WHEREOF, we (grantors) set our hands and seals.
DOUG G FRENCH KRISTIN L FRENCH
STATE OF WASHINGTON,
County of Mason
On this day personally appeared before me KRISTIN L FRENCH and DOUGLAS G
FRENCH, to me known to be the persons described in and who executed the within and
foregoing instrument and acknowledged to me that they signed as their free and
voluntary act and deed for the purposes therein mentioned.
DATED: 9 I2I ? OX `J" p ALL)W,,
n� NOTARY
Notary name printed or typed:I �P v.o +tYV�1^C\1 — �''- ? jB! ?Z
Notary Public in and for the State of:
':1y .Numbs}.:
Residing at: SVQ..lDV1
L
My commission expires: I Z'3l 20 Z o°`?F'•+' sion ' 'f' �''
S IU NOTARY �'.➢_
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0/RECTORS APPROVAL m,.r....m... WATER ALLOCATION EASEMENT NOTES:
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OWNERS
—'a- I DESCRIPTION
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SURVEYORS NOTES l�T
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SURVEY REFERENCES
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AUDITORS CERTIFICATE-- -
AUDITORS ; ALINE LAND SURVEYING,LLC R
`" PROFESSIONAL SURVEYORS
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