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Home My WebLink AboutWEC2000-00222 - WEC Application - 1/26/2001 MASON COUNTY DEPARTMENT OF HEALTH SERVICES 1 PO BOX 1666 SHELTON,WA 98584 Date /17 SHELTON (360)427-9670 FAX (360)427-7798 PLMA (360)482-5269 BE FAIR (360)275-4467 5E TLE (206)464-6968 v�S r;fl; n NE �� , RBI y1A 9-652K WEC PARCEL NUMBER OWNER'S NAME J�PwM, r', SITE ADDRESS q9J qE lweje l/ jk Dr. The well construction for the above site was found to be unsatisfactory for the following reasons: ❑ Cap was not satisfactory ❑ No tag was found on the well ❑ The tag number on the well does not agree with the tag number on the well report ❑ The seal had slumped ❑ No seal was evident ❑ Seal was not to ground surface ❑ Seal was excessively gritty ❑ Voids were found in the seal ❑ Top of well casing was below grade ❑ The well was flowing or showed evidence of other leakage ❑ There is evidence of cascading water ❑ The seal does not appear to be at least eighteen feet long ❑/ Setbacks do not appear to be appropriate Other Gj 4y- 1C ,'o., Ckt L-11 GI l CIT00,C4 CC S:r.C✓ Comments Crw-Jc ,J 1MP h'c 2/26/U 1 ` j 14 , CorYPs 7 (M i If you have any questions, please call me at ext. 293. Stephanie Kenny Environmental Health Specialist CC. Igor Vem { MASON COUNTY DEPARTMENT OF HEALTH SERVICES SURFACE SEAL CONSTRUCTIt3 � III,; I �wA 91" L� � !U60) 7 27SA467 Receipt No. l�F( '� �` '°� AR 1360)427-7791! Date ofPayment - 2- TIDEMARK# Instructions HEALTH SERVICES 1 c,ompletetsartrxre. '� Pay�aeandaukralttbf� amm(mumof��hauta�tadvancaof�rtiRlaiuut lion Ma1tea}leek ta1C Ntm7ti�EFk rt�f �eogata�.afterttdaleFa��mgiva�te�iltis> tt.x#r 8 �dha3tls �� *`r��flr�' +f ��XS' ts�sttenstotN�+ PART 1: ApplicanUParcel Identificatiionnn pv✓1 ,� Site House Address& 4/%/ 1'001yeXW LLC-- J "` Start Cerd# DrdlingFirmName AVI `�, bP-tt_tatAL 1146 , Telephone# > G7 Property Owner Name D,/,0/✓O- Z2�^;;&2 Telephone# BA9— 7d O� i Mailing Addresss RVV Assessor's Parcel Number,2_ a - � 1L Q Subdivision(If applicable) Div_Blk_ of Directions To Site PART 2: Health Depa ment Reyiew (Staff UseOnly) TAG# ��1 YES NO Driller on site?..................................................... ❑/ Isthe well napped&vented?._.............................•. ............................................................. H 11 Is there evidence of a surface seal? ................................................................................... ❑ Is there a 2"annular space on all sides of the casing? ..................................................... ❑ / Hasthe seal slumped? ....................................................................................................... ❑ Is the well flowing or is there evidence of other leakage?.................................................. ❑ Is there evidence of cascading water?............................................................................... ❑ / Is there evidence that the seal Is at least 18 feet long? .................................................... ❑l @/ Do the well site set-backs appear to be appropriate?....................................................... ❑ Pass...................................................................................................................................... ❑ 6/ Comments Ob �f ✓1 Gt l G f I C �AOJ Called in -5 12 Inspector Dfite of Inspection