HomeMy WebLinkAboutWEC2021-00004 - WEC Application - 1/6/2021 „ '• 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
tt ;�� COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
ELMA: 360-482-5269, EXT.400
',. ,Y.-. Building,Planning,Environmental Health,Community Health
FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
ptNurnber
i Payment Information Instructions
�- ii ,` ..�� 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number �1 -0b 2. Attach a plot plan and vicinity map.
V At ❑ Cash 3. Submit this completed application with appropriate fee a minimum
T., Check of 24 hours in advance of initiating well construction. Refer to
GOO
()/ Mason County Environmental Health fee schedule for cost.
�JQ� Date of Payment (4�I7.1 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification
Site Address 11540 Block of Ne North Shore Road, Belfair Wa 98528 Start Card# 424+5-1AI 4 "�I,5
Drilling Firm Knapp Drilling Inc Phone 360-427-8174
Applicant Matt Larsen Phone
Mailing Address 32115 NE 142nd ST
City Duvall State Wa Zip 98109
Parcel Number 3222�11-00230
Directions to Site 11.540, miles out the north shore road,access road on right going up the hill to property,
Is the well site within 100 feet of salt/seawater? Oyes ®No
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? Oyes 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 191h, 2018 per ESSB 6091
aljtkQ .
A plicantlfAgent Signature
PART 2: Health Department Review(Staff Use Only)nlr
YES NO TAG# '1 1— /1cn3 Called In /1(LL gj a ILt
❑ Driller on Site?
- ❑ Is the well capped and Vented?
_E' ❑ Is there evidence of a surface seal? ((�� 22 M ----
G ❑ Is there a 2” annular space on all sides of the casing? I LJ (C O 1J I
/ - ❑ Has the seal slumped?
El <Q Is the well flowing or is there evidence of other leakage? JAN 06 2021
❑ .0" Is there evidence of cascading water?
6" dCQ-- ❑ ❑ Is there evidence that the seal is at least 18 feet long? By
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments in&i( l td 1 06cft b,vth u� Vial rSfete S(tree, r' atur-=-ebllf- Ls1) Jei
❑ Pass ❑ Fail Inspector y, ,313 rcS`r, •-12.3. 0/`� 103 Date y/15/•Zi U
This form may be scanned and availableb for public view on the Mason CountyI Web site. Rev sed:2/7/�8
Z 5 2� h < 61445, e d aYv ch-2� I S fw t o,d i l�- 6(-ck i T e{r; C) e &
a4,,, .0-�M— k'L- ,h.Qa-'-, GZVj 4 2S �9-oirt ktiat il'ski.`v 1 yI `�
/ ' i
1:-', . 1 ' ' I i ' ' 1 ' :''' l " ' ,
, 74, i § /
i
8
, ., ,--,,-
1 1 4 / 4 1 oc.4
.•
..• 8 :
1 " i
ti/ i gl .I
. '
1 i
.
1 g, 0
.,'
,' Lu
' e3
,
i
,, I x / .
1 V ''''' /
/It
i i
t2,'
-
, z • 1 1). '
.0' z / w ,
.-.. , k
z z w /z :,,,.• :!
8
8
z
.4
/
1 - . • ./
c.
/ ,' 3
„ - t
i i /
,./
....„ ;
--..„ • i ..,` 4 ' I / ,
, .
C\i
•
. .,
...
. ....,.„.,.
,
" .
, .
= ,
•‘,-, , ,/ / /
-'--,,, /•
. 8
-•
„
-,.
,
i• 7 ,....,
,...
•
...: /
.....
,.
....
,
. . .
,..
)...4,4 .
.„ .*
..,
S ;4'
/ ,
„,
i
,
i / ., . ,.„. ,.
-„.
/
'°
. ,... 3
'-',-,.. .„•
/ .
.,•,....,,,
a / ,
.-" .
3 /
Fl /
i .. ,...
..,
,
!..) CI)
fieN
`,...„ //
eLl
r
Z.,
< 0
„.,
„ ..
5<- cD
9
o i
. ,c.Q.
r •,.
a.
, 8
-a — /
14
0
/
-0 I ,
. .
.
.
,
,
., .::, 0 .
., . ..
.
. / .R,-- ce ,
!.,2
/ g. ,
,
g ./ g
...
r, ,;
.., (..> ;
:.
(.) ; g
/ /
n,,
„ .
. /
_..... _.........____
. , r ....._...,..................__
„....
....
,
_......,.........._ ,
_
:....,.„,... .
.7......„ ,..
_ ._ ;....
_.__.
,
...,...._
....,.,.....,........
151 ,
, u...,
0 sei
'4= tn,
8 1 .
.,
_.1 •
,
,,„,„,,,, --4..7 ..
8 V) . ,...
i• -7;) ", (b ..,
0
cD , . Li. .•
c
Nr"
.., c •, in ;
rt
c7i 0, ,-, c -,„ •
,
;
3 0 lt0 3 ,,, ,
-a,-
P 6-._ -,....,
..:
g o Lo , u -
iIL. -••• •• ''.•. ./
CL P z
t '65 —m
as--I 14"To in
o• a, C•I 't
2 ..y o
c 0 9
a7o
O cn 0 " \---:
1-
tii 2 1:1).
- 1
,
,,,.'''
. x
1 ,... .. . . ..„ ,.
x - .......,_______________..........._ . . „_............,,......____
i
ul
1
i