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HomeMy WebLinkAboutWEC99-0150 - WEC Application - 8/13/1999 Mason County , . Department of Health Services Nom Ice SURFACE SEAL CONSTRUCTION PERM1qr Shelton, WA 98584 Amount Paid: '� Mznzwk ReceiptNumber: Permit Number:Instructions: AN 13 19" VICES 2 P� Ttputtht� a�itt? bune �a � " ht ts} rttt� ��thpl ppll �_ gY gttet a Y . PAtcta0} : bfi�(31r14} 271A� I PART 1: Applicant/Parcel Identification Site House Address: 1164 E. Mason Lake Road Start Card#: W119310 Drilling Firm Name: Arcadia Drilling Inc Telephone#: 360-426-3395 Owner's Name: Home Services Northwest Telephone#: 360-4,91-5467 Mailing Address: 8705 Hawks Glen Loop SE Olympia, WA 98513 Assessor's Parcel Number: 3 2 ' 3 4 - 3 1 - 9 0 0 4 3 Subdivision(If applicable): Div_Blk Lot Directions To Site: Please see attached map -rage. mWSor, ,yeti card Gnm c-& e+ 3 110L0 uq 30S+ Past- M XKo 60— _ 210- - aMOCLI-BOGd i 1Gk+fr4-mow'FJL :n )WAWA0665'ItLOr p rtu g w I to I , `W_ Rbau 0 lot logic tecd IJOJ End o .ante% UAL.;? . PART 2: ()Heath Department Review(Staff Use Only) TAO#: A Ee q 83 Date Called In: Drilleron site? . .... .... .. . .. . .. . . . . .. . .. . .. .. .. . .. . .. . .. . .. . .. . . . .. . . . . ... . .. ... . .. .. . ❑ P Is the well capped&vented? . . . . .. .. . ... ... .. . . . .. . .. . .. . . . . . . .. . .. . . . . .. . .. . . .. .... . . .. . ❑ Is there evidence of a surface seal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V ❑ 1s there a cont,nuous seal surrounding casing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Has the seal slumped?... ... . .. ... .. . .. . .. . .. . . . .. . .. . .. . . . ... .. . . .... . .. . . .. .. ... .. ❑ -0 Is the well flowing or is there evidence of other leakage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ j Is there evidence of cascading water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ V Is there evidence that the seal is at least 18 feet long? . . '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . T -❑ Do the well site set-backs appear to be appropriate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ PART 3: Conclusions Inspector Comments: Well Construction Satisfactory ❑ Well Construction Unsatisfactory 1Wfj6r Signature Date Wt T JwseawsconMON.wnnwrsnwroaA%wercroNsrwao