HomeMy WebLinkAboutWEC2011-00027 - WEC Application - 4/28/2011 MASON COUNTY APR 2 , 2011
PUBLIC HEALTH
"Always Working For a Safer, Healthier Mason County" 4o ,
415 North 6'"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)427-8442
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NOTICE OF INTENT TO CONSTRUCT A WELL
D 5�6gII�f ' Receipt Number C l WEC:
1. Complete Part 1, Fee$77.00 incomplete applications will be rejected
APR 2 8 2011 D 2. Attach a plot plan and vicinity map
3. Submit this completed application with appropriate feels)$77.00 a minimum of 24
Bvpate Received hours in advance of initiating well construction.
i=--- -- 4. The Mason County Health Dept. must receive notification at least 24 hours prior to
the drilling of the well
PART 1: Applicant/Parcel Identification 1 9 1
Site Address t4D22 0 N , &�) 0\it LL j S art Card#
Drilling Firm _t�AYT l{a I (, Phone
Applicant PhoneS3
� I
Mailing Address
City 01� )� 1� �~ J State Zip Q
Parcel Number �5 e/Z L-1 12 — / t—,� L/
Directions to Site /f lti/ 4 I O C A-8P A& OF &�L fl 0
Is the well site within 100 feet of salt/seawater? ❑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)
YES NO TAG# Called In
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the 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?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments C Wh 1 `
Pass Fail Inspector Date