HomeMy WebLinkAboutWEC2007-00102 - WEC Application - 4/23/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES b,
"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 hfo://www.co.mason.wa.us FAX(360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
E C E I v Receipt Number: 551,00-7-5 2-J WEC: Q O Z
PR 2r 3 2007 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 fee(s)a minimum of 24 hours in
Date ALTH advance if initiating well construction
eive4 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 McEwan Prairie Rd Start Card#WE06471
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Always Painting &Construction Inc. Phone 360-432-3411
Mailing Address E. 301 Wallace Kneeland Blvd Suite 224
City Shelton State WA Zip 98584
Parcel Number 321330090024
From Shelton at Wallace Kneeland Blvd and Brockdale Rd turn North on Brockdale Rd. Then turn
right on McEwan Prairie Rd. Just past railroad tracks look for site on right with Arcadia Drilling sign.
Direction to Site(Third new home site.
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)
YES NO TAG# Y7N Called In —
I, Driller On Site? AL)U 3 q
❑ 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?
4 ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
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