HomeMy WebLinkAboutWEC2021-00149 - WEC Application - 7/27/2021 /yam r`N 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT. 400
I 'Il' r) COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT. 400
^v' Building,Planning,Environmental Health,Community Health
„ FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number a1-L[a.�v 2. Attach a plot plan and vicinity map.
c=aC117: ._( 0 Cash 3. Submit this completed application with appropriate fee a minimum
'NL-i- Check of 24 hours in advance of initiating well construction. Refer to
`� Mason County Environmental Health fee schedule for cost.
�Cl149 Date of Payment )v71 1, 1 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification
\Xi:E.- 30300
Site Address 1835 SE BLOOMFIELD RD, SHELTON Start Card#
Drilling Firm ADVANCED DRILLING Phone 360 273-7735
Applicant DAVID BAYLEY/DJNA LLC Phone 360 490-2492
Mailing Address PO BOX 337
City UNION c� State WA Zip 98592
Parcel Number- 3 (I -D-C1 - /®1t_/
Directions to Site SE HURLEY WALDRIP TO SE OLD OLYMPIC HWY TO SE BLOOMFIELD/SITE
IS ON LEFT UP HILL
Is the well site within 100 feet of salt/seawater? ❑Yes No
If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ❑Yes ❑No
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19th,2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In (XI (I Z‘
❑ ❑ Driller on Site? 12_\
❑ ❑ 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? �L
❑ ❑ Is the well flowing or is there evidence of other leakage? LIL JUL
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? BY:_____
❑ ❑ Do the well site set-backs appear to be appropriate? "
Comments - dor ilri'6G ) - ,Jerr
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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