HomeMy WebLinkAboutWEC2005-00146 - WEC Application - 6/16/2005 MASON COUNT'
DEPARTMENT OF HEALTH SERVICES
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426 W CEDAR ST, PO BOX 1666, SHELTON WA 985B4
SHELTON (360)427-9670 ELMA (360) 4B2-5269 BELFAIR (360) 275-4467
WEB http7//www.co.mason.wa.us FAX (360)427-7796
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
Receipt Number: WEC:� �D/ (�/.
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
in advance of initiating well construction.
Date Received 4. The Mason C'ourify Health Dept. must receive notification of least 24fiburs nor o
the drilling of the well
PART 1:Applicant I Parcel Identification
Site Address Willow Blue Lane LOT 4 Start Card# W190249
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Campbell Properties of Olympia, Inc Phone 360-357-7053
Mailing Address 211 73rd Avenue NE
City Olympia State WA Zip 98506
Parcel Number 321367500040
Directions to Site From h 1 ton nrnraati Nrth on Rt RT 4 anti Frnroati to inn of hill aft.
Deer Creek Store take a lft on Lavender Lane proceed 1 /3 mile and take rght st
intersection (Willow Blue Lane)-proceed 1 /4 mle to bottom of hill and take right
Is the well site within 100 feet of salt/seawater? LjYes ®No at hard 90--proceed up hill to site.
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes ®No
Connie Williams for Arcadia Drilling Inc.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only) 1
YES NO TAG # Called In Z C,
❑ ❑ 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? °" r
❑ ❑ Do the well site set-backs appear to be appropriate? ;
Comments
Pass Fail Inspector Date
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