HomeMy WebLinkAboutWEC2007-00128 - WEC Application - 5/21/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES C
"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 hftl)7//WWW.co.mason.wa.us FAX(360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
E C E I V ED Receipt Number:,55Z06 7- Vto WEC: 07-IZA
MAY 212001 1 Complete Part 1,incomplete applications will not be accepted
2 Attach a plot plan and vicinity map
ENVIRONMENTAL 3 Submit this completed application with appropriate feels)a minimum of 24 hours in
Datel2eceived 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 2390 McEwan Prairie Rd Shelton, WA Start Card#WE06660
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Darrell & Margie Chamberlin Phone 360-790-1115
Mailing Address 50 SE Shadowood Blvd
City Shelton State WA Zip 98584
Parcel Number 321330090023
From Wallace Kneeland Blvd, turn left on Brockdale Rd, then right on McEwan Prairie Rd, after RR
tracks look for site on right with Arcadia Drilling sign, this is the center lot of the three recently
Direction to Sitedeveloped lots
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 ®No
Connie Williams (for)Arcadia Drilling Inc
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
S NO TAG# /�L\k RO U 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?
❑l X Is there evidence of cascading water?
�{� ❑ Is there evidence that the seal is at least 18 feet long?
�Jl�f' ❑ Do the well site set-backs appear to be appropriate?
Comments 714 O�
Pass Fail Inspector Dale C `
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