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CONTRACT ` 1
JEFFERSON COUNTY, WASHINGTON
THIS AGREEMENT, made and entered into this day of ,Se- kW--, 2019, between the
COUNTY OF JEFFERSON, acting through the Jefferson County Commissioners under and by virtue of Title 36,
R.C.W, as amended and Oasis Well Drilling Inc_. of Port Angeles, WA hereinafter called the Contractor.
WITNESSETH:
That in consideration of the terms and conditions contained herein and attached and made a part of this agreement,
the parties hereto covenant and agree as follows:
1. That the Contractor herein will undertake and complete the following described work: Establish and maintain
safe access, create and implement a plan for managing displaced water, safeguard soils, and decommission three
wells in a manner consistent with Ch. 173-160-381 WAC, the Washington Department of Ecology Variance dated
July 8, 2019 (Exhibit F), and as described in the Scope of Work. The wells are located at 161 Roders St., 231
Rodgers St. and 280 Fremont St., in Quilcene, WA. The work schedule is to be coordinated with the project manager
to reduce impacts of activities to surrounding property owners.
The Contractor will be reimbursed for all work performed under the terms of this contract in an amount not
exceed twelve thousand four hundred and twenty-six dollars ($12,426.00). All work will be performed in accordance
with and as described in the AIA Document A201 2007 `General Conditions of the Contract for Construction' which
are by this reference incorporated herein and made a part hereof. The Contractor shall perform any alteration in or
addition to the work provided in this contract and every part thereof. The Well Decommissioning Inspection
applications have been received by Jefferson County Environmental Public Health (Exhibit G).
In the event that archaeological or historic materials are discovered during project activities, work in the
location of discovery and immediate vicinity must stop instantly; the area must be secured, and notification must be
provided to concerned Tribe's cultural staff and cultural committees, the Recreation and Conservation Office, and the
State Department of Archaeology and Historic Preservation. See Exhibit H, Plan and Procedures for the
Unanticipated Discovery of Cultural Resources and Human Skeletal Remains.
If human remains are discovered during project activity, work in the immediate vicinity must stop, the area
must be secured, and notification must be provided to concerned Tribe's cultural staff and cultural committees, the
Recreation and Conservation Office, the State Department of Archaeology and Historic Preservation, the coroner,
and local law enforcement in the most expeditious manner possible according to RCW 68.50.
The Contractor shall complete the described work within 30 days' time after the Notice to Proceed; with a
final completion date no later than October 31, 2019.
The Contractor shall provide and bear the expense of all equipment, work and labor of any sort whatsoever
that may be required for the transfer of materials and for constructing and completing the work provided for in this
contract and every part thereof.
2. The County of Jefferson hereby promises and agrees with the Contractor to employ, and does employ the
Contractor to furnish the goods and equipment described and to furnish the same according to the attached
specifications and the terms and conditions herein contained, and hereby contracts to pay for the same according to
the attached specifications and the schedule of unit or itemized prices hereto attached, at the time and in the manner
and upon the condition provided for in this contract. The County further agrees to employ the Contractor to perform
any alterations in or additions to the work provided for in this contract that may be ordered and to pay for the same
under the terms of this contract and the attached specifications at the time and in the manner and upon the conditions
provided for in this contract.
3. The Contractor for himself, and for his heirs, executor, administrators, successors, and assigns, does hereby
agree to the full performance of all the covenants herein contained upon the part of the Contractor.
4. Prior to commencing work, the Contractor shall obtain at its own cost and expense the following insurance
from companies licensed in the State with a Best's rating of no less than A: VII. The Contractor shall provide to the
County Risk Manager certificates of insurance with original endorsements affecting insurance required by this clause
prior to the commencement of work to be performed.
The insurance policies required shall provide that thirty (3 0) days prior to cancellation, suspension, reduction
or material change in the policy, notice of same shall be given to the County Risk Manager by registered mail, return
receipt requested, for all of the following stated insurance policies.
If any of the insurance requirements are not complied with at the renewal date of the insurance policy,
payments to the Contractor shall be withheld until all such requirements have been met, or at the option of the County,
the County may pay the renewal premium and withhold such payments from the moneys due The Contractor.
All notices shall name the Contractor and identify the agreement by contract number or some other form of
identification necessary to inform the County of the particular contract affected.
A. Workers Compensation and Employers Liability Insurance. The Contractor shall procure and
maintain for the life of the contract, Workers Compensation Insurance, including Employers Liability
Coverage, in accordance with the laws of the State of Washington.
B. General Liability(1) - with a minimum limit per occurrence of one million dollars ($1,000,000) and
an aggregate of not less than two million dollars ($2,000,000) for bodily injury, death and property damage
unless otherwise specified in the contract specifications. This insurance coverage shall contain no limitations
on the scope of the protection provided and indicate on the certificate of insurance the following coverage:
1. Broad Form Property Damage with no employee exclusion;
2. Personal Injury Liability, including extended bodily injury;
3. Broad Form Contractual/Commercial Liability including completed operations (contractors only);
4. Premises - Operations Liability (M&C);
5. Independent Contractors and Subcontractors; and
6. Blanket Contractual Liability.
(1) Note: The County shall be named as an additional insured party under this policy.
C. Automobile (2) - with a minimum limit per occurrence of $1,000,000 for bodily injury, death and
property damage unless otherwise specified in the contract specifications. This insurance shall indicate on
the certificate of insurance the following coverage:
1. Owned automobiles;
2. Hired automobiles; and,
3. Non -owned automobiles.
(2) Note: The County shall be named as an additional insured party under this policy.
Any deductibles or self-insured retention shall be declared to and approved by the County prior to the
approval of the contract by the County. At the option of the County, the insurer shall reduce or eliminate deductibles
or self-insured retention or The Contractor shall procure a bond guaranteeing payment of losses and related
investigations, claim administration and defense expenses.
The Contractor shall include all subcontractors as insured under its insurance policies or shall furnish separate
certificates and endorsements for each subcontractor. All insurance provisions for subcontractors shall be subject to
all of the requirements stated herein.
2
Failure of The Contractor to take out and/or maintain any required insurance shall not relieve The Contractor
from any liability under the Agreement, nor shall the insurance requirements be construed to conflict with or
otherwise limit the obligations concerning indemnification.
It is agreed by the parties that insurers shall have no right of recovery or subrogation against the County
(including its employees and other agents and agencies), it being the intention of the parties that the insurance policies
so affected shall protect both parties and be primary coverage for any and all losses covered by the above described
insurance. It is further agreed by the parties that insurance companies issuing the policy or policies shall have no
recourse against the County (including its employees and other agents and agencies) for payment of any premiums
or for assessments under any form of policy. It is further agreed by the parties that any and all deductibles in the
above described insurance policies shall be assumed by and be at the sole risk of The Contractor.
Vehicle and equipment parking on-site during the project is at the owner's own risk.
It is agreed by the parties that judgments for which the County may be liable, in excess of insured amounts
provided herein, or any portion thereof, may be withheld from payment due, or to become due, to the Contractor until
such time as the Contractor shall furnish additional security covering such judgment as may be determined by the
County.
The County reserves the right to request additional insurance on an individual basis for extra hazardous
contracts and specific service agreements.
Any coverage for third party liability claims provided to the County by a "Risk Pool" created pursuant to
Ch. 48.62 RCW shall be non-contributory with respect to any policy of insurance the Contractor must provide in
order to comply with this Agreement.
If the proof of insurance or certificate of coverage indicating the County is an "additional insured" to a
policy obtained by the Contractor refers to an endorsement (by number or name) but does not provide the full text
of that endorsement, then it shall be the obligation of the Contractor to obtain the full text of that endorsement and
forward that full text to the County within 30 days of the execution of this Agreement.
The County may, upon the Contractor's failure to comply with all provisions of this contract relating to
insurance, withhold payment or compensation that would otherwise be due to the Contractor.
5. The Contractor shall comply with all Federal, State, and local laws and ordinances applicable to the work to
be done under this Agreement. This Agreement shall be interpreted and construed in accord with the laws of the
State of Washington and venue shall be in Jefferson County, WA.
The Contractor shall indemnify and hold the County, and its officers, employees, and agents harmless from
and shall process and defend at its own expense, including all costs, attorney fees and expenses relating thereto, all
claims, demands, or suits at law or equity arising in whole or in part, directly or indirectly, from the Contractor's
negligence or breach of any of its obligations under this Agreement; provided that nothing herein shall require a
Contractor to indemnify the County against and hold harmless the County from claims, demands or suits based
solely upon the conduct of the County, its officers, employees and agents, and; provided further that if the claims or
suits are caused by or result from the concurrent negligence of. (a) the Contractor's agents or employees; and, (b)
the County, its officers, employees and agents, this indemnity provision with respect to claims or suits based upon
such negligence, and/or the costs to the County of defending such claims and suits, etc., shall be valid and
enforceable only to the extent of the Contractor's negligence, or the negligence of the Contractor's agents or
employees.
Claims against the County shall include, but not be limited to assertions that the use and transfer of any
software, book, document, report, film, tape, or sound reproduction of material of any kind, delivered hereunder,
constitutes an infringement of any copyright, patent, trademark, trade name, or otherwise results in an unfair trade
practice or an unlawful restraint of competition.
3
The Contractor specifically assumes potential liability for actions brought against the County by
Contractor's employees, including all other persons engaged in the performance of any work or service required of
the Contractor under this Agreement and, solely for the purpose of this indemnification and defense, the Contractor
specifically waives any immunity under the state industrial insurance law, Title 51 R.C.W. The Contractor
recognizes that this waiver was specifically entered into pursuant to provisions of R.C.W. 4.24.115 and was subject
of mutual negotiation.
6. The Contractor's relation to the County shall be at all times as an independent Contractor, and nothing
herein contained shall be construed to create a relationship of employer-employee or master -servant, and any and
all employees of the Contractor or other persons engaged in the performance of any work or service required of the
Contractor under this Agreement shall be considered employees of the Contractor only and any claims that may
arise on behalf of or against said employees shall be the sole obligation and responsibility of the Contractor.
7. The Contractor shall not sublet or assign any of the services covered by this contract without the express
written consent of the County or its authorized representative. Assignment does not include printing or other
customary reimbursable expenses that may be provided in an agreement.
8. Nothing in the foregoing clause shall prevent the County, at its option, from additionally requesting that the
Contractor deliver to the County an executed bond as security for the faithful performance of this contract and for
payment of all obligations of the Contractor.
For contracts of $150,000 or less, the County and the Contractor may agree that in -lieu of the Contract
Bond; the County will withhold 10% of the Contract amount in accordance with R.C.W 39.08.010. If applicable,
the Contractor will indicate this option on Exhibit D.
9. The Contractor will declare a management option of the statutory retained percentage on Exhibit E.
XQ Limited Small Works Project per RCW 39.04.155(3): Performance Bond and Retainage Waived
INDEX OF EXHIBITS
-1 Exhibit A: Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
X❑ Exhibit B: Certification of Compliance with Wage Payment Statues
F] Exhibit C: Contract Bond, Jefferson County, Washington
X] Exhibit D: Contractor's Declaration of Option for Contracts for Less Than $150,000
❑X Exhibit E: Contractor's Declaration of Option for Management of Statutory Retained Percentage
4
IN WITNESS WHEREOF, the Contractor has executed this instrument on the day and year first below written, and
the Board of County Commissioners has caused this instrument to be executed by and in the name of said County of
Jefferson the day and year first above written.
Executed by the Contractor q/ 1% '2019
Contractor:
(Please print)
By: rd �'X Z/
ML
(Please print)
(Signature)
State of Washington Contractor Registration Number
OASISWD917MG
Exp. 03/15/2020
5
COUNTY OF JEFFERSON
BOARD OF COMMISSIONERS
a ef��
Kate VDean,Ch
David W. Sullivan, Member
Greg Brotherton, em
A oved astof m only:
C• L Date:��
Philip Hunsucker, Chief Civil Deputy Prosecuting Atty
Jefferson County Prosecuting Attorney's Office
SCOPE OF WORK
This well decommissioning project involves three wells located in three different locations:
1. 161 Rodgers St., APN 991200407
2. 231 Rodgers St., APN 991200304
3. 280 Fremont St., APN 991201101
Work may be suspended by the County at any time due to rain or adverse soil conditions. Contractor should
bear in mind that the location of the Big Quilcene River main stem may someday coincide with one or more of
the decommissioned well location(s).
• Decommission the wells located at 231 Rodgers St. and 280 Fremont St., in Quilcene, WA in a manner
consistent with Ch. 173-160-381 WAC.
• Decommission the well located at 161 Rodgers St. in Quilcene, WA in a manner consistent with Ch. 173-
160-381 WAC and the Washington Department of Ecology Variance dated July 8, 2019.
• Schedule work in coordination with the project manager to coincide with minimum ground water elevation
and reduce impacts of activities to surrounding property owners and traffic.
• Create and implement a plan for managing displaced water. Submit the plan to the project manager at least
five business days ahead of any scheduled work.
• Observe all requirements in the event that archaeological or historic materials or human remains are
discovered. Exhibit H, Plan and Procedures for the Unanticipated Discovery of Cultural Resources and
Human Skeletal Remains, must be readily available at the worksite whenever the Contractor is present.
• Provide documentation on disposal of all well components and casings.
• Obtain necessary permits and authorizations from Jefferson County Public Works and utility providers.
• Safely locate, discontinue, disconnect and remove existing utility connections.
• Safely locate buried utilities and protect them from damage.
• Protect existing trees from damage to the extent feasible.
• No trespassing onto adjacent properties.
• Finely grade or rake all disturbed areas in preparation for seeding.
• Properly dispose of all debris and litter from the project.
• Clean tires of mud and debris prior to entering roadways.
• Establish and maintain safe access, safeguard soils, and protect each site from erosion.
EXHIBIT A
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION
The Contractor certifies to the best of its knowledge and belief, that it and its principals:
(1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;
(2) Have not within a 3 -year period preceding this proposal been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation
of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and
(4) Have not within a 3 -year period preceding this contract had one or more public transactions (Federal, State,
or local) terminated for cause or default.
Where the Contractor is unable to certify to any of the statements in this certification, such Contractor shall attach an
explanation.
Name of Contractor (Please print)
F
Title of Authorized Representative (Please print)
of Authorize Representative
❑ I am unable to certify to the above statement. An explanation is attached.
7
EXKMIT B
CERTIFICATION OF COMPLIANCE WITH WAGE PAYMENT STATUTES
The bidder hereby certifies that, within the three-year period immediately preceding the bid solicitation date (W
), the bidder is not a "willful" violator, as defined in R.C.W 49.48.082, of any provision of chapters 49.46, 49.4 , or
49.52 R.C.W, as determined by a final and binding citation and notice of assessment issued by the Department of
Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Name
of Authorized Official*
e/_
Printed Name
Title
/ Pyr% cilgC1eS
ate City State
Check One:
Sole Proprietorship ❑ Partnership ❑ Joint Venture Corporation
State of Incorporation, or if not a corporation, State where business entity was formed:
If a co -partnership, give firm name under which business is transacted:
* If a corporation, proposal must be executed in the corporate name by the president or vice-president (or any
other corporate officer accompanied by evidence of authority to sign). If a co -partnership, proposal must be
executed by a partner.
r;�
EXHIBIT C
CONTRACT BOND
JEFFERSON COUNTY, WASHINGTON
KNOW ALL MEN BY THESE PRESENTS:
That
and
of
as Surety, are jointly and severally held
JEFFERSO, e penal sum of
for the payment which we jointly and severally bind ourselves, or
successors and assign firmly by these presents.
as Principal,
bound unto the COUNTY OF
Dllars ($ ),
administrators, and assigns, and
The condition of ' bond is such that WHEREAS, on the day of , A.D., 20 'the said
Principal herein, exe ed a certain contract with the County of Jefferson, by
the terms, conditions and provision'sof which contract the s ' , Principal herewith,
agrees to furnish all materials and do cettain work, to -w' . That the said Principal herein will undertake and complete the
following described work:
Washington, as per maps, plans and specificat ons made
attached, and is now referred to and by thig reference is i
as if here set forth at length.
in Jefferson County,
a part of said contract, which contract as so executed, is hereunto
iborporated herein and made a part hereof as full for all purposes
NOW THEREFORE, i e Principal herein shall fai lly and truly observe and comply with the terms,
conditions and provisions of id contract, in all respects and shall w and truly and fully do and perform all matters and
things by the said Princi undertaken to be performed under said con upon the terms proposed therein, and within
the time prescribed erein, and until the same is accepted, and shall pay a laborers, mechanics, subcontractors and
materialmen, an 11 persons who shall supply such contractor or subcontracto with provisions and supplies for the
carrying on o uch work, and shall in all respects faithfully perform said contract a ording to law, then this obligation
to be voi otherwise to remain in full force and effect.
WITNESS our hands this day of , 20
PRINCIPAL
M.
0
P
SURETY COMPANY
By:
By:
Attorney-in-fact
Address of local office and agent
of surety company:
EXHIBIT D
CONTRACTOR'S DECLARATION OF OPTION FOR CONTRACTS FOR LESS THAN $150,000
A. A Contract Bond will be provided as required.
Date
Signed
B. In lieu of providing a Contract Bond, the County will withhold 10% of the Contract amount.
� w
Date l Signed
10
EXHIBIT E
CONTRACTOR'S DECLARATION OF OPTION FOR MANAGEMENT
OF STATUTORY RETAINED PERCENTAGE
A. I hereby elect to have the retained percentage of this contract held in a fund by the Owner until (30) days
following final acceptance of the work.
-
Date 7 ` Signed
B. I hereby elect to have the Owner deposit the retained percentage of this contract in an interest bearing account,
not subject to withdrawal until after final acceptance of the work.
Date
Signed
C. I hereby elect to have the Owner invest the retained percentage of this contract from time to time as such
retained percentage accrues.
I hereby designate
as the repository for the escrow of said funds.
I hereby further agree to be fully responsible for payment of all costs or fees incurred as a result of placing said
retained percentage in escrow and investing it as authorized by statute. The Owner shall not be liable in any way for
any costs or fees in connection therewith.
Date
Signed
D. I hereby elect to provide a Retainage Bond in accordance with R.C.W 60.28.011.
Date Signed
11
EXHIBIT F
VARIANCE TO CHAPTER 173-160 WAC FOR 161 RODGERS ST., QUILCENE, WA
4
%TATE Of WASHINGTON
DEPARTMENT Of EC010(-;Y
IT) tlrtx 47775 + Olvarapk Waahirtgtart 4fl:SO4-77?5 • Q60? 407.6100
771 few t#:t.hirAg(iwt RPMs Servicrl _ IN"otm; ss-ith a speech diwb44 t.rn c'.,tl 877-H.34-6347
July 8.2019
Taml Pokorny
Jefferson County Public Health
615 Sheridan Street
Port l'ownsend. WA 98368
Re: Variance Request to Chapter 173-160 Washington Administrative Code (WAC) for
Decommissioning a Dug Water Well at the at 161 Rogers St., Quilccne, WA in the NW "/a
SW ",a, Section 24, Township 27 North, Range 2 Voest W.M., JelTerson County, Tax
Parcel No. 991200407
Dear Tami Pokorny
This letter is in response to your variance request dated May 21,'2019.. concerning
decointnissioning a water well. You are requesting a variance to the Minimum Standards .for the
Construction and Maintenance of Wells, Chapter 173-160 WAC. Specifically, your request is to
decommission a dug well that is impractical to meet WAC 173-164-381(3). The complete
method is described as followed;
What decommissioning methods cannot be met?
W,4C 173-160-38i(3)(1y; Dug wells that are not cast -in-place must hare a minimum of three feet
Qf sealing material in contact with native .soil below land surface
Describe reasors why standard cannot be met.
Casing material is a solid approximately 3' wide diameter, 4.S thick. almost 20' deep concrete
in }eery shallow water table with sand and gravel lithology1 Excavating to a depth necessary to
meet requirements woidd be eery unsafe, with water table and unstable soils.
Describe the alternative decommissioning method that will provide equal or greater
protections than those provided by the minimum standard.
Fill bottom 10' with chlorinated pea gravel, thea 9' of unhydrated bentonite chips then cap 1 'of
concrete, leaving the curbing in place.
After an investigation, interview, and review of information available, a variance is hereby
granted•to WAC 173-160=381(3). Ecology Ault allow the well to he decommissioned as soon as
workers and equipment are available and using the method you have proposed. This variance is
granted under the following coed do s:
Q*
12
Fami Pokomv
page
I Well decominissionino must stai-L within one year u!'this variance.
Well decommissioning must comply with
Jefferson County rule-, and regulations.
3. A notice of intent to construct a water well must be filed and the fee paid at least 72 hours
before starting construction (in accordance with Chapter 173-160-151 WA(.).
4. All well construction shall 1:v performed by a licensed driller as set forth by
Chapter 173-162 WAC and Revised Code of Washington (RCW't 18.10
5. This dug well must Ix- decommissioned as described in your methods and using the
waling materials listed in WAC 173-160-381(3)(a)(iii):
Di(g weiLvshall he seaied ivith either urkdraied be atonite. near cement, neat cement
grout, or ca rcrete. The use of coittrolletl denshyfill WDF), bentrinite shirrv. orf�y ash is
prohibired
6. If the Big Quile-ene River starts to migrate and erodes the old concrete curbing of this
.veil, the concrete curbing must be cut dow-ii so it is not a.-.ilc-,v hazard in the middle of
*he river chairnel.
The driller must submit Water Well Reivris describing the decommissioning to Ecology
(Southwest Regional office) wi"rl 30 days after completion of the work. Attach a copy
(if this variance to each well report.
8. The driller must inform Ecology (John Prarch, 360-407-0297) two business days before
any well decommissioning work begins. The driller must make the site accessible to My.
Pearch to inspect any ajid.!orall well decommissioning work.
9. Thedriller mu -;t inform.lefferson County (Susan Porto 360-3195-9444) two business days
before any decommissioning NAVOrk begins. The driller mast make the site accessible to
Susan Porto to inspectany widior all decommissioning work. JetTerson CountY may have
additional requirements. Please contact them as sour, as possible.
10. With the exception of the provisions set forth (above) in this variance, all federal, state,
and local requirements shall apply.
YOUR RIGHT TO APPEAL
You have a right to appeal this -ariance to the Pollution Control Hearing Board (PCHR) within
1 0 d
W days of the date of receipt of this ii-arianec. The appeal process is g veme by Chapter
4"),?-;13RCC and Chapter 371-08WAC. "Uate orf receipt" is defined in R("Jv 43.2113.t�tt bit}.
'la appeal you must do the following within 30 days of the date ol'rciceipt of this variance:
File your appeal and a copy of variance with the PCHB (see addresses below), Filing
means actual receipt by the PCHB during regular business hour-,.
13
Tami Pokomy
July a. 2019
Page 3
Scree a cop), Of your appeal and this variance on Ecology in paper form, -Ley mail Or in
person. (,Scc addresses below.) E-mail is not accepted.
You must also comply with other applicable requirements in Chapter 43.21 B RCW and Chapter
371-08 WAC.
ADDRESS AND LOCATION INFORMATION
Stred Addresses I I
Department of Ecology
Ann: Appeals Processing Desk
300 Desmond Drive SE
Lacey, WA 98503
Pollution Control Hearings Board
1111 lirael RD SW
STE 301
Turnwater, WA 98501
Department of Ecology
Attn: Appeals Processing Desk
110 Box 47608
Olympia, WA 98504-7608
Pollution Control Hearings Board
PO Box 40903
Olympia. WA 98504.-0903
For a"fional lt!f6rmatian visit the Environmental Hearings Qjice
I.Vebsite: hup,vvtvw. jjk), L, agov, To find laws and agency rules visit the Washington State
Legislature (Vebsite.- ftil
SIGNATURE
WT
Michael J. (54tl &LIAt Date
Section Manatter
0
Water Resources Program
John carch- 11.1-16
car
_
'trul
Weltonstniction Coordinator ate
jqa,461,�i
By Certified Mai] 9489 0090 0027 6066 5482 815
Tauri Pokorny, Jefferson Count}y Public Health, TPokorny(z&ojefterson, wa.us
Susan Porto, Jetlbrson County Public Health, sp(wtw co-jefterson.wa-us
14
EXHIBIT G
APPLICATIONS FOR WELL DECOMMISSIONING INSPECTIONS
15
Jefferson County Public Health
�< r. Environmental Health Department
615 Sheridan Street
Port Townsend, WA 98368
-a Tel: 360.385.9444 Fax: 360.379.4487
\0 Email: drinkingwater&o.jefferson.wa.us
Website: www.ieffersoncountypublichealth.org
For Offlce Use:
Date Recd Receipt #
Amt�� USR # 1!5-007.
Comments:
Application for Well Construction, Reconstr
Decommissioning Inspection
This packet is for (Check one):
r New Well ro;� Reconstruction r Decommission r&—
APPLICANT AND SITE INFORMATION
Applicants
Applicants Name Tam[ Pokorny
Owners Name (if different from applicant) Jefferson County
Applicants Mailing Address JCEPH 615 Sheridan St.
Parcel Tax ID# 991200407
Section 24 Township 27N Range 2W
JAN 14 2o19
Phone 360/379-4498
Phone 360/316-9870
Zip Code 98368
s"XN { '1
Site Address and directions to site: 181 Rodgers St. Quilcene - From Quilcene, travel south on Rodgers SL Site Is on the Left (East) after
passing through Linger Longer Intersection
Drilling Company _ Driller Name License #
Anticipated Start Date Start Card No. (if received)
SITE PLOT PLAN
The plot plan must show the items listed below. Please draw the site in the allocated section on the reverse side of this
document or attach ar,Il►1lIcE clod ri rcrrt , 31� this ann[icgtian if needed.
• Indicate North with an arrow and draw the property boundaries;
• Show all natural features, such as areas of permanent or seasonal surface water, streams, rivers, bluffs, etc.;
• Show existing roads and other constructed or developed features (to help in locating the site);
• Show all potential sources of contamination. These include, but are not limited to: approved septic areas (SPAAD), installed septic
systems, septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other potential
source listed in WAC 173-160-171( including those located on adjacent lots);
• Show all existing wells, including all wells that are to be decommissioned;
• Indicated the well radius of 100', including all potential sources of contamination on the lot and the affected portions of adjacent lot(s);
• Show measurements from the proposed well or decommissioned well to at least two (2) property lines and to all sources of
contamination and septic approvals. including those located on adjacent lots:
Please uaderstftnd the followigg items when siting your well:
• Consider locating the well 100 feet or more from any property line to ensure full control of the wells protective zone. This may be a
requirement if the parcel is in a subdivision with plat conditions that requires the well to be located 100' from all property lines.
• The well must be located 100 feet minimum from any sources of contamination, including: approved septic areas (SPAAD), installed
septic systems and septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other
potential source listed in WAC 173-160-171.
• The well must be located 1,000 feet minimum from the property line of an operating or closed landfill or solid waste facility.
• If this well is located in a stream, any area of seasonal inundation or permanent surface water, then further well construction
requirements will be needed.
If this well is located in the inventory area (WRIA 17, WAC 173-517), then further well use requirements will be applied.
NOTE: If parcel can be served by an approved public water supply, the water purveyor will have the first right of refusal to use the well.
Please be aware that this may delay your application as the purveyor evaluates their conditions of approval on a case-by-case basis.
Page 1 of 2
r%W
-JA /V
i
Ex
�attK C , Jefferson County Public Health
Environmental Health Department
615 Sheridan Street
" Port Townsend, WA 98368
Tel: 360.385.9444 Fax: 360.379.4487
iys jfl tr«X�� Email: drinkingwater&o.Jefferson.wa.us
Website: www.jeffersoncountypublichealth.org
For Office Use-
Date Rec'd Receipt #
Amt Z?,b USR #
Comments:
Application for Well Construction, Recon
Decommissioning Inspection
This packet is for (Check one):
r New Well ro` ReconstructionDecommission ❑�
Applicants Name Tam! Pakomy
Owners Name (if different from applicant) Jefferson County
Applicants Mailing Address JCEPH 615 Sheridan St_
Parcel Tax ID# 991200304 Section 24 Township 27N _ Range
ction or
-QCI -Yt
ma;n iN 14 2D19
NtAI mO—*rY—
Phone 360/379-4498
Phone 360/316-9870
Zip Code 88368
Site Address and directions to site: 231 Rodgers St. Quilcene - From Qullcene, travel south on Rodgers St. Site Is on the Left (East)
and last house before the road ends at the Big Qulk:ene River.
Drilling Company Driller Name License #
Anticipated Start Date Start Card No. (if received)
SITE PLOT PLAN
The plot pian must show the Items listed below. Please draw the sitg in the allocated section on the reverse side of this
document or attach another document to this application If needed.
• Indicate North with an arrow and draw the property boundaries;
• Show all natural features, such as areas of permanent or seasonal surface water, streams, rivers, bluffs, etc.;
• Show existing roads and other constructed or developed features (to help in locating the site);
• Show all potential sources of contamination. These include, but are not limited to: approved septic areas (SPAAD), installed septic
systems, septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other potential
source listed in WAC 173-160-171( including those located on adjacent lots);
Show all existing wells, including all wells that are to be decommissioned;
Indicated the well radius of 100', including all potential sources of contamination on the lot and the affected portions of adjacent lot(s);
Show measurements from the proposed well or decommissioned well to at least two (2) property lines and to all sources of
contamination and septic .approvals. including those located on adjacent lots;
Ptepse understand the fallowing items when siting your well:
• Consider locating the well 100 feet or more from any property line to ensure full control of the wells protective zone. This may be a
requirement if the parcel is in a subdivision with plat conditions that requires the well to be located 100' from all property lines.
• The well must be located 100 feet minimum from any sources of contamination, including; approved septic areas (SPAAD), installed
septic systems and septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other
potential source listed in WAC 173-160-171.
• The well must be located 1,000 feet minimum from the property line of an operating or closed landfill or solid waste facility.
• If this well is located in a stream, any area of seasonal Inundation or permanent surface water, then further well construction
requirements will be needed.
• If this well Is located in the Inventory area (WRIA 17, WAC 173-517), then further well use requirements will be applied.
NOTE: If parcel can be served by an approved public water supply, the water purveyor will have the first right of refusal to use the well.
Please be aware that this may delay your application as the purveyor evaluates their conditions of approval on a case-by-case basis.
Page 1 of 2
f RECEI]HFAT
W
E+ m
JAN 14 25
�P.►Ei�a~�q��ENvr pM4ENTAL PUBLI
';0N
Jefferson County Public Health
Environmental Health Department
1
615 Sheridan Street
Port Townsend, WA 98368
4y
Tel: 360.385.9444 Fax: 360.379.4487
%0 »
Email: drinkingwater&o.Jefferson.wa.us
Website: www.weffersoncountypyblichealth.org
For Office Use:
Date Recd 1 `(� tq Receipt #
Amt Z—Z8.60 USR #
Comments:
Application for Well Construction, Recon
Decommissioning Inspection
This packet is for (Check one):
r New Well r Reconstruction commission F3
APPLICANT AND SITE INFORMATION
Applicants Name Tam! Pokorny
Owners Name (if different from applicant) Jefferson County
Applicants Mailing Address JCEPH 615 Sheridan St.
Parcel Tax ID# 991201101 Section 24 Township 27N
Range M
r its- �or
E - Q - E �IV E
nci t _ JAN 14 2019
i- - ...,
F. Nv1n� E ��t HEAL7►t
Phone 360/379-4498
Phone 380/316-9870
Zip Code 58368
Site Address and directions to site: 280 Fremont Ave. Qullcene - From Quilcene, travel south on Rodgers St. Turn Left (East) on Linger Longer Road.
Turn Left (East) on Fremont Ave. Site Is on your Right (South) side of road.
Drilling Company Driller Name License #
Anticipated Start Date Start Card No. (if received)
SITE PLOT PLAN
t1'i7r
The plott show the Items listed heign.draw the site in iie—amig-sectimon the reverse side of this
docurvent or attacb another document to this application if needed.
• Indicate North with an arrow and draw the property boundaries;
• Show all natural features, such as areas of permanent or seasonal surface water, streams, rivers, bluffs, etc.;
• Show existing roads and other constructed or developed features (to help in locating the site);
• Show all potential sources of contamination. These include, but are not limited to: approved septic areas (SPAAD), installed septic
systems, septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other potential
source listed in WAC 173-160-171( including those located on adjacent lots);
• Show all existing wells, including all wells that are to be decommissioned;
Indicated the well radius of 100', including all potential sources of contamination on the lot and the affected portions of adjacent lot(s);
9 Show measurements from the proposed well or decommissioned well to at least two (2) property lines and to all sources of
contamination and septic approvals, including those located on adjacent lots.
Please understand the followiga items when siting your well:
• Consider locating the well 100 feet or more from any property line to ensure full control of the wells protective zone. This may be a
requirement if the parcel is in a subdivision with plat conditions that requires the well to be located 100' from all property lines.
• The well must be located 100 feet minimum from any sources of contamination, including: approved septic areas (SPAAD), installed
septic systems and septic reserve areas, barns, stock yards, sewage lagoons, hazardous waste sites, marine shorelines, or any other
potential source listed in WAC 173-160-171.
• The well must be located 1,000 feet minimum from the property line of an operating or closed landfill or solid waste facility.
• If this well is located in a stream, any area of seasonal inundation or permanent surface water, then further well construction
requirements will be needed.
• If this well is located in the inventory area (WRIA 17, WAC 173-517), then further well use requirements will be applied.
NOTE: If parcel can be served by an approved public water supply, the water purveyor will have the first right of refusal to use the well.
Please be aware that this, may delay your application as the purveyor evaluates their conditions of approval on a case-by-case basis.
Page 1 of 2
EXHIBIT H
PLAN AND PROCEDURES FOR THE UNANTICIPATED DISCOVERY OF CULTURAL RESOURCES AND
HUMAN SKELETAL REMAINS
16
Page 11
PLAN AND PROCEDURES FOR THE UNANTICIPATED DISCOVERY OF CULTURAL RESOURCES AND
HUMAN SKELETAL REMAINS
1. INTRODUCTION
The following Unanticipated Discovery Plan (UPD) outlines procedures to follow, in accordance with
state and federal laws, if archaeological materials or human remains are discovered. It is the
responsibility of the grant recipient (Sponsor) to ensure all staff (and subcontracted entities) working on
the project is familiar with this plan.
2. RECOGNIZING CULTURAL RESOURCES
A cultural resource discovery could be prehistoric or historic. Examples include:
• accumulation of shell, burned rocks, or other food related materials,
• bones or small pieces of bone,
• area of charcoal or very dark stained soil with artifacts,
• stone tools or waste flakes (i.e. an arrowhead, or stone chips),
• clusters of tin cans or bottles, logging or agricultural equipment that appears to be older than
50 years,
• buried railroad tracks, decking, or other industrial materials. When in doubt, assume the material
is a cultural resource.
3. ON-SITE RESPONSIBILITIES
STEP 1: STOP WORK. If an employee, contractor, subcontractor or volunteer believes that he or
she has uncovered a cultural resource at any point in the project, all work in the immediate area
of the discovery must stop (typically a 10 foot radius, but depends on site conditions). The
discovery location should be secured at all times.
STEP 2: NOTIFY MONITOR. If there is an archaeological monitor for the project, notify that
person. If there is a monitoring plan in place, the monitor will follow its provisions.
STEP 3: NOTIFY PROJECT MANAGEMENT. Contact the RCO Grants Manager and sponsoring
entity's Project Manager.
Recreation and Conservation Office
RCO Grants Manager
(360)-902-3000
If you can't reach the Grants Manager, contact the project's alternate point of contact or RCO's
Cultural Resources Coordinator
Sarah Thirtyacre
(360) 902-0243
sarah.thirtyacre@rco.wa.gov
The Grants Manager or their designated Alternate Contact will make all other calls and notifications.
Plans Procedures for the Unanticipated Discovery of Cultural Resources or Human Skeletal Remains 2015
Page 12
If human remains are encountered, treat them with dignity and respect at all times. Cover the remains
with a tarp or other materials (not soil or rocks) for temporary protection in place and shield them from
being photographed. Do not call or speak with the media about the remains specifically.
4. FURTHER CONTACTS AND CONSULTATION
A. Project Manager's Responsibilities:
• Protect Find: The grant sponsor's Project Manager is responsible for taking appropriate steps to
protect the discovery site. All work will stop in an area adequate for the total security,
protection, and integrity of the resource. Vehicles, equipment, and unauthorized personnel will
not be permitted to traverse the discovery site. Work in the immediate area will not resume until
treatment of the discovery has been completed following provisions for treating
archaeological/cultural material as set forth in this document.
Direct Construction Elsewhere On-site: The grant sponsor's Project Manager may direct
construction away from cultural resources to work in other areas prior to contacting the
concerned parties.
• Contact the Department of Archaeology and Historic Preservation (DAHP): If the DAHP has not
yet been contacted; the RCO Grants Manager will do so.
Identify Find: The grant sponsor's Project Manager and RCO will ensure that a qualified
professional archaeologist examines the find to determine if it is archaeological. This will either
be an archaeological consultant hired by the Project or staff from DAHP.
■ If the discovery is determined not archaeological, work may proceed with no
further delay.
If the discovery is determined to be archaeological, the Project Manager will
continue with notification.
If the discovery is human remains or funerary objects, the Project Manager will
ensure that the DAHP State Physical Anthropologist examines the find. If the
discovery is determined to be human remains, the procedure described in
Section 5 will be followed.
Notify DAHP: The grant sponsor's Project Manager and RCO will contact the involved federal or
permitting agencies (if any) and the Department of Archaeology and Historic Preservation
(DAHP).
Department of Archaeology and Historic Preservation:
Robert G. Whitlam, Ph.D. Dr. Guy Tasa
State Archaeologist State Physical Anthropologist
(360) 586-3080 (360) 586-3534
rob.whitlam@dahp.wa.gov guy.tasa@dahp.wa.gov
The RCO will contact the interested and affected Tribes.
Plans Procedures for the Unanticipated Discovery of Cultural Resources or Human Skeletal Remains 2015
Pa g e 13
B. Further Activities
Archaeological discoveries will be documented as described in Section 6.
Construction in the discovery area may resume as described in Section 7.
5. SPECIAL PROCEDURES FOR THE DISCOVERY OF HUMAN SKELETAL MATERIAL
Any human skeletal remains, regardless of antiquity or ethnic origin, will at all times be treated with
dignity and respect.
• If the project occurs on federal lands (e.g., national forest or park, military reservation) or Indian
lands (e.g., reservations, allotments, communities) the provisions of the Native American Graves
Protection and Repatriation Act of 1990 apply, and the responsible federal agency will follow its
provisions. Note that state highways that cross federal and Indian lands are on easements and
are not owned by the state.
• If the project occurs on non-federal lands, it will comply with applicable state laws, and the
following procedure:
A. Notify Law Enforcement Agency or Coroner's Office:
• In addition to the actions described in Sections 3 and 4, the Project Manager will
immediately notify the local law enforcement agency or coroner's office.
• The coroner (with assistance of law enforcement personnel) will determine if the
remains are human, whether the discovery site constitutes a crime scene, and
will notify DAHP.
Participate in Consultation:
• Per RCW 27.44.055, RCW 68.50, and RCW 68.60, DAHP will have jurisdiction over
non -forensic human remains.
C. Further Activities:
• Documentation of human skeletal remains and funerary objects will be agreed
upon through the consultation process described in RCW 27.44.055, RCW 68.50,
and RCW 68.60.
• When consultation and documentation activities are complete, construction in
the discovery area may resume as described in Section 7.
6. DOCUMENTATION OF ARCHAEOLOGICAL MATERIALS
Archaeological deposits discovered during construction will be assumed eligible for inclusion in the
National Register of Historic Places under Criterion D per 36CFR800.13(c) until a formal Determination
of Eligibility is made. If the project does not have a federal nexus/compliance requirement, contact the
Project Manager or DAHP regarding the possible need for an Emergency Excavation Permit per RCW
27.53. In general, expect that:
All prehistoric and historic cultural material discovered during project construction will be
recorded by a professional archaeologist on State of Washington cultural resource site or isolate
form using standard techniques. Site overviews, feature, and artifacts will be photographed;
stratigraphic profiles and soil/sediment descriptions will be prepared for subsurface exposures.
Discovery locations will be documented on scaled site plans and site location maps.
Plans Procedures for the Unanticipated Discovery of Cultural Resources or Human Skeletal Remains 2015
Page 14
Cultural features, horizons and artifacts detected in buried sediments may require further
evaluation using hand -dug test units. Units may be dug in controlled fashion to expose
features, collect samples from undisturbed contexts, or interpret complex stratigraphy. A test
excavation unit or small trench might also be used to determine if an intact occupation surface
is present. Test units will be used only when necessary to gather information on the nature,
extent and integrity of subsurface cultural deposits to evaluate the site's significance.
Excavations will be conducted using state-of-the-art techniques for controlling provenience.
Spatial information, depth of excavation levels, natural and cultural stratigraphy, presence or
absence of cultural material, and depth to sterile soil, regolith, or bedrock will be recorded for
each probe on a standard form. Test excavation units will be recorded on unit -level forms,
which include plan maps for each excavated level, and material type, number, and vertical
provenience (depth below surface and stratum association where applicable) for all artifacts
recovered from the level. A stratigraphic profile will be drawn for at least one wall of each test
excavation unit.
• Sediments excavated for purposes of cultural resources investigation will be screened through
1/8 -inch mesh, unless soil conditions warrant 1/4 -inch mesh.
• All prehistoric and historic artifacts collected from the surface and from probes and excavation
units will be analyzed, catalogued, and temporarily curated. Ultimate disposition of cultural
materials will be determined in consultation with the federal agencies (if any), DAHP, and the
affected tribes.
If assessment activity exposes human remains (burials, isolated teeth, or bones), the process described
in Section 5 above will be followed.
7. PROCEEDING WITH CONSTRUCTION
Project construction outside the discovery location may continue while documentation and assessment
of the cultural resources proceed. A Cultural Resources Specialist (either from DAHP, a consulting Tribe,
or a professional consultant) must determine the boundaries of the discovery location. In consultation
with DAHP and affected tribes, the RCO and the grants sponsor will determine the appropriate level of
documentation and treatment of the resource. If federal agencies are involved, the agencies will make
the final determinations about treatment and documentation.
Construction may continue at the discovery location only after the process outlined in this plan is
followed and DAHP (and the federal agencies, if any) determine that compliance with state and federal
laws is complete.
Plans Procedures for the Unanticipated Discovery of Cultural Resources or Human Skeletal Remains 2015
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615 Sheridan Street
Port Townsend, WA 98368
,Ae ihson www.JeffersonCountyPublicHealth.org
51 is Heacilt Consent Agenda
August 8, 2019
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Stuart Whitford, Environmental Public Health Director
Tami Pokorny, Natural Resources Program Coordinator
DATE:
SUBJECT: Agenda Item — Contract with Oasis Well Drilling, Inc.; Upon signature —
October 31, 2019; $12,426
STATEMENT OF ISSUE:
Jefferson County Public Health requests Board approval of the Contract with Oasis Well Drilling; Upon signature
— October 31, 2019; $12,426
ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S:
This agreement is to establish and maintain safe access, create and implement a plan for managing displaced
water, safeguard soils, and decommission three wells located at 161 Rodgers St., 231 Rodgers St. and 280
Fremont St., in Quilcene, WA
FISCAL IMPACT/COST BENEFIT ANALYSIS:
This Contract is funded by RCO #15-1189, Big Quilcene River Floodplain Key Pieces, and the Public Works
Quilcene Flood Account.
RECOMMENDATION:
JCPH management requests approval of the Contract with Oasis Well Drilling, Inc.; Upon signature — October
31, 2019; $12,426
REVIEWED BY:
chili orley, Cou ty minis rator
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
Date
Always working for a safer and healthier community
Environmental Public Health
360-385-9444
(f) 360-379-4487
CONTRACT REVIEW FORM
CONTRACT WITH: Oasis Well Drilling, Inc.
(Contractor/Consultant)
CONTRACT FOR: Well Decommissioning
TRACKING NO.: WQ-19-164
AEQi n ur -Tcd�er3l,2019
COUNTY DEPARTMENT: Jefferson County Public Health
For More Information Contact: Tami pl l(;
2 2019
Contact Phone #: x498
RETURN TO: Jenny RETURN BY: %�1,krxatpcQ1 NIERS
(Person in Department)ate)
AMOUNT: $12,426
Revenue
Expenditure
Matching funds Required
Source(s) of Matching Funds
$12,426
PROCESS: ❑
Exempt from Bid Process
❑
Consultant Selection Process
❑
Cooperative Purchase
❑
Competitive Sealed Bid
❑
Small Works Roster
❑
Vendor List Bid
4 (
RFP or RFQ
❑
Other - MOU
Step 1: REVIEW BY, S E ENT
Review
Date Re '
X�APPROVED
FORM ElRetur r revision (See Comments)
Comments
Step 2: REVIEW B70710ENG ATTORNEY
Review by( Philip C. Hunsucker
Date Reviewed: Chief Civil Deputy Prosecuting Attorney
APPROVED AS TO FORM Returned for revision (See Comments)
Comments
Step 3: (If required) DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY
Step 4: CONTRACTOR/CONSULTANT SIGNS APPROPRIATE NUMBER OF ORIGINALS
Step 5: SUBMIT TO BOCC FOR APPROVAL
Submit original Contract(s), Agenda Request, and Contract Review form. Also, please send 2 copies of just the Contract(s)
(with the originals) to the BOCC Office. Place "Sign Here" markers on all places the BOCC needs to sign. MUST be in
BOCC Office by 4:30 p.m. TUESDAY for the following Monday's agenda.
(This form to stay with contract throughout the contract review process.)