HomeMy WebLinkAboutWEC2008-00082 - WEC Application - 5/22/2008 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
"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 http-//www.co-mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
ECEIVED
Receipt Number. y514d- rU WEC: 0
MAY 2 2 Z008 1 Complete Part 1, incomplete applications will not be accepted
EP-)V'Rk0NMEN AL 2 Attach a plot plan and vicinity map
F iEALTH 3 Submit this completed application with appropriate fee(s)a minimum of 24 hours in
Date Received 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 McEwan Prairie Tr 1-D Start Card# WE08433
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Nathan Stout Phone 360-490-3198
Mailing Address PO Box 2371
City Shelton State WA Zip 98584
Parcel Number 321334090024
From Shelton travel out on Brockdale Rd. Turn right on McEwan Prairie Rd. Look for site on left just
Direction to Sitebefore Mason Lake Rd. See attached map on back
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# �54 F CP Z Z 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?
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