HomeMy WebLinkAboutWEC2007-00016 - WEC Application - 1/26/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
426 W. CEDAR 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) 427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
143 'S30In2i3S HlltJ3Receipt Number: � W0-7 -� l 5!5 WEC: 0-7' 119
1. Complete Part 1, incomplete applications will not be accepted
338 9 Z NVr 2. Attach a plot plan and vicinity map
3. Submit this completed application with appropriate fees a minimum of 24
a3ABUdd hours in advance of initiating a well
4. The Mason County Health Department must receive notification at least 24
hours prior to the drilling of the well
Date Received
PART 1: Applicant/Parcel Identification
Site Address Mason Lake Drive Shelton, WA 3 Start Card
#WE06122
Drilling Firm: Arcadia Drilling Inc. Phone:
360.426.3395
Applicant Richard Dickinson Phone:
360.520.7378
Mailing Address 6321 Ne Ion Drive SW Olympia, WA 98512
Parcel Numbers 321331090013
Directions to Site From Shelton travel north on Hwy 3 and turn left on Mason Lake
Rd, look for site on right with Arcadia Drilling Sign after McEwan Prairie Rd. Right
after new Hi-Line home.
Is the well site within 100 feet of salt/seawater? ❑ Yes ®No
If yes, a variance from DOE is required. Have you applied /received a variance? ❑ Yes ®No
Connie Williams for Arcadia Drilling Inc.
Applicant/Agent Signature
PART 2: Health Department Review ( ff U e Onl )
YES NO TAG # f U /y 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?
❑ -fD' Has the seal slumped?
❑ R Is the well flowing or is there evidence of other leakage?
❑ n Is there evidence of cascading water?
( ❑ Is there evidence that the seal is at least 18 feet long?
[� ❑ Do the well site set-back appear to be appropri te?
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