HomeMy WebLinkAboutWEC2007-00242 - WEC Application - 10/25/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
"Always Working For a Safer, Healthier Mason County" :
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA(360)482-5269 BELFAIR(360)275-4467
WEB http://www.co.mason.wa.us FAX(360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
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Receipt Number. i57-yel— C/& 7 WEC: 0"1-
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OCT 2 5 2007 1 Complete Part 1,incomplete applications will not be accepted
0 2 Attach a plot plan and vicinity map ENVIRONMENTAL
HEF,LT H 3 Submit this completed application with appropriate fee(s)a minimum of 24 hours in
Date Received advance if initiating well construction
4 The Mason County Health Dept. Must receive notification at least 24 hours prior to the
drilling of the well
PART 1: Applicant 1 Parcel Identification
Site Address 350 Arnolds Way Hoodsport WA Start Card# WE07619
Drilling Firm_ Arcadia Drilling Inc Phone 360-426-3395
Applicant Brook Lawless Phone 360.877.9072
Mailing Address P.O. Box 484
City Hoodsport State WA Zip 9$548
Parcel Number 323312200000
From Shelton, travel north on Hwy 101 past Hoodsport. After Tides Restaurant turn left on Terrace
Rd. (one lane). Follow up hill to right on Westward Way. Turn right again on first gravel road by
feedstore sign. Follow straight as it turns into Arnolds Way. Follow this to end. Well site located on
LH side of road near mobile home at end. Be careful when exiting onto Hwy 101. It may be advisable
Direction to Sit eonly.to exit the way you entered instead of real exit as you can turn south from this road instead of north
Is the well site within 100 feet of salt/seawater? ❑Yes ®No
If yes, a variance from DOE is required. Have you applied/received (check one) a variance? [-]Yes L�No
Connie Williams (for)Arcadia Drilling, Inc.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) 1
YES NO TAG# Called In
❑ Driller On Site?
❑ Is the well capped and vented?
❑ Is there evidence of a surface seal?
0 Is there a 2"annular space on all sides of the casing?
jEr❑ Has the seal Slumped?
1] 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?
❑ Do the well site set-backs appear to be appropriate?
Comments
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