HomeMy WebLinkAboutWEC2010-00102 - WEC Application - 10/6/2010 MASON COUNTY ,
PUBLIC HEALTH
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON „3EB)h ip/96�cELMA o maso36wa48s FAX (2-5269 360)217R-442)275-4467
NOTICE OF INTENT TO DECOMMISSION A WELL ��f /`
Receipt Number: �— WEC: to _ (\,, I'
• �+ V ' 1. Complete Part 1, ($113.00 Fee). Incomplete applications will be rejected
2. Attach a plot plan and vicinity map.
/ L 3. Submit this completed application with appropriate fee(s)a minimum of 24 hours in
£ nn advance of initiating well construction.
�aCe Received J
�P 4. The Mason County Health Dept. must receive notification at least 4 hours prior to
�I. . the drilling of the well.
PART 1.'Applicant I Parcel) Identification,
Site Address Start Card# 6 / p ./
Drilling Firm �C/�/�'�n/� �� �( ���� �G Phone Q 27 a l `4
Applicant %/li[ L)D Phone
Mailing Address
City ,� �l/ State _� — Zip 5
Parcel Number � r
Directions to Site
Is the well being decommissioned to allow siting of potential source of contamination (ie. septic drainfiel )? ❑Yes ®No
If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ❑Yes No
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
Y Called In /d
ES NO TAG#
❑ Driller on Site?
❑ Has the well been decommissioned in accordance with WAC 173-160?
Is it a cased well?
❑ Is a well report available that shows a surface seal?
Method of
Decommission ?
and Comments
Pass � Fail Inspector-
,l Date a
�R�vil 1-9-2008