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Home My WebLink About021820_ca02 �V615 Sheridan Street Port To ' wnsend, WA 98368 �. oge ason www.JeffersonCountyPublicHealth.org Public Healt Consent Agenda February 4,2020 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Mrey, Coy Ar FROM: Pinky Philip Mingool, Interim EnvironmentaluntdministPublic Health Director Tami Pokorny, Natural Resources Program Coordinator DATE: SUBJECT: Agenda Item — Contract with Oasis Well Drilling, Inc.; Upon signature — December 31, 2020; $11,306.57 STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of the Contract with Oasis Well Drilling, Inc; Upon signature — December 31, 2020; $11,306.57 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 two wells located at 151 Fremont Ave. and 10 Fremont Ave., in Quilcene, WA. FISCAL IMPACT/COST BENEFIT ANALYSIS: This Contract is funded by RCO #16-1480, Lower Big Quilcene Floodplain Acquisitions and #17-1052, Big Quilcene Riparian Protection and matched by WA Dept. of Ecology Terry Husseman and Hood Canal Salmon Enhancement Group's Floodplains by Design funding. RECOMMENDATION: JCPH management request approval of the Contract with Oasis Well Drilling, Inc.; Upon signature — December 31, 2020; $11,306.57 REV BY: --; /`�z-=-1522/O_C:7 Jas Philip Morley, Cdua' A dministrator Date Community Health Environmental Public Health Developmental Disabilities 360-385-9444 360-385-9400 (f) 360-379-4487 360-385-9401 (f) Always working for a safer and healthier community CONTRACT JEFFERSON COUNTY,WASHINGTON THIS AGREEMENT,made and entered into this day of ,2020,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 two wells in a manner consistent with Ch. 173-160-381 WAC and as described in the Scope of Work.The wells are located at 10 Fremont Ave. and 151 Fremont Ave. in Quilcene, WA. The work is anticipated to occur in April of 2020 and is to be coordinated with the project manager. The Contractor will be reimbursed for all work performed under the terms of this contract in an amount not exceed eleven thousand three hundred and six dollars and fifty-seven cents($11,306.57).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 Public Health(Exhibit F). 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 G, 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 14 days' time after the Notice to Proceed. 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. 1 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(30)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. 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 2 (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. 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 3 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. ❑X Limited Small Works Project per RCW 39.04.155(3): Performance Bond and Retainage Waived INDEX OF EXHIBITS X Exhibit A: Certification Regarding Debarment, Suspension,Ineligibility,and Voluntary Exclusion X Exhibit B: Certification of Compliance with Wage Payment Statues Exhibit C: Contract Bond,Jefferson County,Washington nExhibit 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 X Exhibit F: Applications for Well Decommissioning Inspections X Exhibit G: Plan and Procedures for the Unanticipated Discovery of Cultural Resources and Human Skeletal Remains 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 ,2020 Contractor: (Please print) By: (Please print) (Signature) State of Washington Contractor Registration Number OASISWD917MG Exp. 03/15/2020 COUNTY OF JEFFERSON BOARD OF COMMISSIONERS Greg Brotherton,Chair David W. Sullivan, Member Kate Dean,Member Approved as to form only: 0-AA2 2D Philip C. unsucker Date Chief Civil Deputy Prosecutor 5 SCOPE OF WORK This well decommissioning project involves three wells located in three different locations: 1. 10 Fremont Ave., APN 991200401 2. 151 Fremont Ave., APN 991200505 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 at least one of the decommissioned well location(s). • Decommission the wells located at 10 Fremont Ave. and 151 Fremont Ave., in Quilcene, WA in a manner consistent with Ch. 173-160-381 WAC. • Schedule work in coordination with the project manager. • Observe all requirements in the event that archaeological or historic materials or human remains are discovered. Exhibit G,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, authorizations, and clearances 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. • Establish access to well heads while minimizing disturbance to the site. • 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. 6 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) Name and Title of Authorized Representative(Please print) Signature of Authorize Representative I am unable to certify to the above statement. An explanation is attached. EXHIBIT B CERTIFICATION OF COMPLIANCE WITH WAGE PAYMENT STATUTES The bidder hereby certifies that,within the three-year period immediately preceding the bid solicitation date( ),the bidder is not a"willful"violator, as defined in R.C.W 49.48.082,of any provision of chapters 49.46,49.48, 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. Bidder's Business Name Signature of Authorized Official* Printed Name Title Date City State Check One: Sole Proprietorship n Partnership 111 Joint Ventures 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. EXHIBIT C CON 1RACT BOND JEFFERSON COUNTY,WASHINGTON KNOW ALL MEN BY THESE PRESENTS: That ,of ,as Principal, and , as Surety, are jointly and severally held and bound unto the COUNTY OF JEFFERSON,the penal sum of Dollars ($ ), for the payment of which we jointly and severally bind ourselves, or heirs, executors, administrators, and assigns, and successors and assigns,firmly by these presents. The condition of this bond is such that WHEREAS,on the day of ,A.D.,20 , the said ,Principal herein,executed a certain contract with the County of Jefferson,by the terms,conditions and provisions of which contract the said ,Principal herewith, agrees to furnish all materials and do certain work,to-wit: That the said Principal herein will undertake and complete the following described work: , in Jefferson County, Washington,as per maps,plans and specifications made a part of said contract,which contract as so executed,is hereunto attached,and is now referred to and by this reference is incorporated herein and made a part hereof as full for all purposes as if here set forth at length. NOW THEREFORE, if the Principal herein shall faithfully and truly observe and comply with the terms, conditions and provisions of said contract,in all respects and shall well and truly and fully do and perform all matters and things by the said Principal undertaken to be performed under said contract,upon the terms proposed therein,and within the time prescribed therein, and until the same is accepted, and shall pay all laborers, mechanics, subcontractors and materialmen, and all persons who shall supply such contractor or subcontractor with provisions and supplies for the carrying on of such work,and shall in all respects faithfully perform said contract according to law,then this obligation to be void,otherwise to remain in full force and effect. WITNESS our hands this day of ,20 PRINCIPAL SURETY COMPANY By: 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. Date Signed 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 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 60.28.01 1. Date Signed EXHIBIT F APPLICATIONS FOR WELL DECOMMISSIONING INSPECTIONS • -- Jefferson County Environmental For Office Use: Public Health Department Date Rec'd Receipt# If J ti. ' 615 Sheridan Street AmtCheck# r-1, i 'A:A..,,, Port Townsend,WA 98368 USl2# b Tel: 360.385.9444 Fax: 360.379.4487 Comments ic nn Email: drinkingwaterpco.jefferson.wa.us Website: www leffersoncountvpublichealth.ora Application for Well Construction, Reconstruction or Decommissioning Inspection This packet is for(Check one): New Well Reconstruction / Decommission RReplacemerr APPLIC•-kNT AND SITE INFOR\LOTION Applicant Ohunet Name Tauri rokomy for Jefferson County Phoye 300-37b-44618 Applicant'O++ner Mailing.address Jcoei a iF Shendan St Port Townsend.WA Zip Code 98368 Applicant Owner Email Address tpokomynco.;e'ferson.wa.us Parcel Tax IDa 691200105 Section 24 Township 27N Range 2W Site Address and directions to site if i Fremont Ave .Qwlcene,WA From Hwy 101.Sout? on Rodgers St.Left on Lsnger Longer Re .Right on Fremont Ave., First nouse(blue)on right DriIlinv Company Oasis Dolling Duller Name he+th Winter License# OASISWD917MG Anticipated Stan Date 4/1120 Stan Card No.(if recen•ed) SITE PLOT PLAN The plot plan roust show the items listed below. Please draw the site in the allocated sectiou on the reverse•.ide of this document at attach another document to this applicationif needed. • Indicate North with an avow and draw the property bounidanes: • Show all natural features.such as areas of permanent or seasonal surface water.streams.rivers.bluffs. etc.. • Show esrsti.iig 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.burls,stock yards sewage lagoons.letzardous waste sues.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(?)property Imes and to all sources of contamination and septic approvals.including those located on adjacent lots: Please understand the following items when siting your•well: • C'onsider locating the well 100 feet at 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(SPA D).installed sepnc 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 iu the inventor 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 condmons of approval on a caw-try-case basis. Page l of 2 • PLOT PL.A—N r,___. ,,,,....,,,,.. _., ____ ftp I a 1 8 i - , weN emote u 0 i ; C khO to • i Greirithwahmalit N I 3y signing this application foto.the j pfte ettL'on'lte atte_ra that the information provided harem t:true and correct to the be:i of-.vow knowledge ?my material falsehood or any out;:tots of a tnatenal fact tirade by the app:main ow17awith respect to the:application way result m the denial of a butldmg ptrtant tanlinne the subject wel:.or may require e ab an nn nt of the;ub e.^t well. I agree to provide acre::and tight of entry to Jefferson C comity employee:.. representatives or agent:for the prupose of applacaton review and any required inspections ,Ace:s and right efental-to the applicant:property or structure -.ball occur during regular business hour..I further agree to save.tadenmify and hold harmless Jefferson County again•t al:haathtes.judgments court cost.. attorney fees and expense:which mar in any way accuse against Jefferson County as a result of or in consequence of tht>apphcanoa dtt&itnf of the proposed we::,or any subsequent inspections. Applicant/01111N.Si=uattrre� _ • _ r.. Date 2/31`. e. c, THIS SEC TION TO BE C OMIPLETED BY JEFFERSON COUNTY 1Vater service at 11RIA I"Sub-basin SIPZ ZONE? C'lassrficatron Stied Etsaironxieutal Health Specialist Date Canstntctfon Inspected(Y N) Dnller on site-(TNF Date By Notes: Page 2 of 2 Jefferson County Environmental For Office Use: Public Health Department Date Recd Receipt# 615 Sheridan Street Amt. Check# Port Townsend,WA 98368 USR# Tel:360385.9444 Fax:360.379.4487 Comments Health Email:drinkingwaterlco jefferson.wa.us Website:wwwietfersoncountvoutblichealth.orq Application for Well Construction, Reconstruction or Decommissioning Inspection This packet is for(Check one): New Well EIReconstruction LL Decommission IT Replacement APPLICA.\T AND SITE INFORMATION ApplicantrownerName Tami Pokomy for Jefferson County Phone 360-3794498 Applicantr'Oylaer Mailing Address JCPH 815 Sheridan St.Port Townsend.WA Zip code 88368 Applicantr'Owrier F*m s l Address tpokomyeco.jefferson_wa.us Parcel Tax 1D# 9912°0401 Section 24 Township 27N Range 2W Site Address and directions to site: 10 Fremont Ave..Outcene,WA From Hwy 101.South on Rodgers St., Left on Linger Longer Rd.,Right on Fremont Ave.,First house(blue)on right. Drilling Company Oasis Drilling Driller Name Keith Winter License# OASISWD917MG Anticipated Start Date 411120 Start Card No.(if received) SITE PLOT PLAN The plot Ulan must show the items listed below. grease draw the site in the allocated section on the reverse side of this document or attack another document to this application if needed. • Indicate North with an arrow and draw the property botmdanes. • Show all natural features,such as areas of permanent or seasonal surface water,streams,rimers,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 segue approvals_iucludiug.those located on adjacent lots; Please understand the following items when shine 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 dosed landfill or solid waste facility. • If this well is located in a stream.any area of seasonal iuttndadon or permanent surface water,then farther well construction requirements will be needed. • If this well is located in the inventory area(WRIA 17,WAC 173-517),then further well use requiteaunts 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 PLOT PLAN alb- mommas .It .. .51,0Vi.1 Fremont Avenue 100' well illi se, , . , . . IS 1 *'4' 9 V.,"Pt 1 i '4: 4 s c . ,. . Se OS 7 % VT in By signing this application form,the oplicant/oirtart attests that the mformation provided herein is true and correct to the best of your knowledge. Any material falsehood or any omission of a material fact made by the applicangovmer with respect to this application may result in the denial ala building permit utilizing the subject well,or may require abandonment of the subject well I apes to provide access and right of entry to Jefferson County employea, representatives or agents for the purpose of application nniew and any required inmections. Access and right of entry to the applicant's property or structure shall occur dining regular hennas hours.I further apse to save,indemnify and hold harmless Jefferson County apinst all habikties,judgments,court costs, attorney fees and expenses which may in any way moue against Jefferson Comity as a result of or in consequence of this application.drilling of the proposed well,or any subsequent inspections. ,.. ,_ Applicant/Owner Signaturee_.:. —E-10c., -----, - Dare _2./31.70z_O ' ) THIS SEC TION TO BE COMPLETED BI.JEFFERSON COUNTY Water service area? WRIA 17 Sub-basin SIPZ ZONE? Classification Signed Environmental Health Specialist Date Construction Inspected(Y'N) Driller on site?(YN) Date By Notes: 'age 2 of 2 EXHIBIT G PLAN AND PROCEDURES FOR THE UNANTICIPATED DISCOVERY OF CULTURAL RESOURCES AND HUMAN SKELETAL REMAINS 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 (DAH P). 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 Page 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. B. 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. 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