HomeMy WebLinkAboutWEC2008-00062 - WEC Application - 5/6/2008 r
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES IIh
"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 htto://www.co.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
E C E I V E Receipt Number: h<ZOOA 473 WEC: 0zf
MAY Q G 2008 1 Complete Part 1, incomplete applications will not be accepted
2 Attach a plot plan and vicinity map
ENVIH�-i1I��pp�II�''ffi�L�.�ihq i-AL 3 Submit this completed application with appropriate fee(s) a minimum of 24 hours in
Date REcdro2tl' 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 Mason Lake Drive E. Shelton, WA 98584 Start Card # WE08306
Drilling Firm Arcadia Drilling, Inc Phone 360-426-3395
Applicant Reeves Hill LLC Phone 360-426-2646
Mailing Address PO Box 729
City Shelton State WA Zip 98584
Parcel Number 321331090012
From Shelton, travel north on Hwy 3 then turn left on
Direction to Site Mason Lake Road. After McEwan Prairie Rd, look for site
Is the well site within 100 feet of salt/seawater? es o
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# 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
Pass Fail Inspector Date
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