HomeMy WebLinkAboutWEC2006-00317 - WEL Application - 1/30/2007 Fh
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426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)2754467
WEB FAX (360)427-7798
APPLICAMN FOR WELL•SURFACE SEAL CONSTRUC ION`PjERRMFT
Receipt Number.. _L'7: WEC:"�^ "
1. Complete Part 1, incomplete applications will not be accepted
2. Attach a plot plan and vicinity map
3. Submit this completed application with appropriate fee(s)a minimum_of 24 hours
Date Received in advance of initiating well construction.
4. The Mason County Health Dept must receive notification at least 24 hours prior to
the drillinq of the well
PART 1:Applicant/Parcel IdsntW]cation
Site Address NE 30 Haven Place Start Card# WE05789
Drilling Firm Nicholson Drilling Inc Phone 360-876-4421
Applicant Michael & Penny Fullaway Phone 953-747-0663
Mailing Address
City Federal Wa-y State Zip 980,73
Parcel Number 223305000024
Directions to Site See attached ma
Is the well site within 100 feet of sat I seawater? ❑Yes ®No
If yes, a variance from DOE is required.Have you applied/received(circle one)a variance? ®Yes []No
An
[Agent Signature
PART 2:Heath Deparf mt Review(Staff Use Only)
YES NO TAG#
called In
❑ Driller on Site?
❑ Is the well capped arhd Vented?
Is there evidence of a surface seal?
Is there a 2'annular space on all sides of the casing?
Has the seal Stumped?
Q ❑ 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 iorrg?
Q Q Do the well site set-backs appear to be appropriate?
Comments
l' pass' Fail Inspector
• r Date