HomeMy WebLinkAboutWEC2005-00311 - WEC Application - 11/9/2005 K-k4 GN COUNT)
` ' bEPARTMENT OF HEALTH SERVICES
42t3 W CEDAR ST, PD BOY 1666, SHELTON WA 913SEW
SHELTUN (360) 427-9670 ELM (360) 482-5265 BELFAIR (360127"-4467
WEB htln://www.co.masori.wEi.us FAY, (360) 427-779B
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
RECEIVED Receipt I�Jumber: SAS - j°)q ( WEC
Nei/ 0 9 2005 1. Complete Par[ 1, incomplete applications will not be accepted
2. Attach a plot plan and vicinity map
" ALTH SERVICES, ; 3. Submit this completed application with appropriate feels) a minimum of 24 hours
n advance of initiating well construction.
—-- 4.- The N)Iasoff County Heath-Dept. must—Pceioe notification ai least 24"-h5Urs prior to—, —
Date Received the drilling of the well
PART 1: Applicant l Par el ldentifica 'o
Site Address, Catfish/MIkkelsen Road jStar1 Card # W207926
Drilling.Firm Arcadia Drilling Inc. Phone 360-426-3395
Applicant Shawn & Nicole Kinney Phone 360-426-9891
Mailing Address E 590 Dartmoor Drive
City Shelton State WA ZIP 98584
Parcel (dumber
Directions to Site From Shelton travel north on HWY 3 and turn left on Mason. Lake. Rd
just past Catfish Lake Rd look for site on right with Arcadia Drilling sign
Is the well site within 1 DO feet of salt I seawater? ❑Yes EjNo
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? ❑Yes JEND
Connie Williams for Arcadia Drilling Inc
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YE NO TAG# Called In
g ❑ Driller on Site?
❑ Is the well capped and Vented?
t : ❑ 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 [here evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feel long?
F1 ❑ Co the well site set-backs appear to be appropriate?
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