HomeMy WebLinkAboutWEC2021-00108 - WEC Application - 5/11/2021 ( - � MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON: 360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
\,' `j/ Building,Planning,Environmental Health,Community Health ELMA: 360-482-5269, EXT.400
f FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number'(Y/14 2. Attach a plot plan and vicinity map.
GI 0 Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
60 ®C Date of Payment 6 / 4. Mason County Public must receive notification at least 24 hours
t D prior to the drilling of the well.
PART 1: Applicant/Parcel Identification
Site Address CU7_ E., VOr' /`E0-1, c.CCl Start Card # ell J Q !l0
Drilling Firm L/J./1 S i\Jr i j IA() Phone a(oO 'e5�/13^2`
Applicant �t n-�'<� `{�1�. �)rC.�{1V Phone ZljZ" q g j- S 2
Mailing Address 3OZ r i-k, Baft-, -Rd / I
City OLL� State (/ l Zip Q 527
Parcel Number 27- _ - Q Q Q
Directions to Site '� k Of ! 0 t. 1* 1 n
Is the well site within 100 feet of salt/seawater? ❑YesNo
If yes, a variance from DOE is required. Have you applie /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 19`h, 2018 per ESSB 6091.
A is nt/ gent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 912-2/2.-1 r . Z(
❑ Driller on Site?
KA
vbse f� ❑ Is the well capped and Vented?
c� ,,, Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing? D L Ll LS � NE
14O{a e l "❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage? MAY 11 2021 LI
r}ti9s• ❑ ❑ 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 : 1(, ;M. rp-t rd,..5.� a¢t@,J4-5 L o c�� k. w- .. C te. i b toi.:}-ii\(Ai e...S
❑ Pass ❑ Fail Inspector I v`!A/% )A4 �-g-. , date �'J'I2r� (2_1
e_ „`11 � 416"-,,,,,`0- d , �0'fie_r 11; k/Y\a-neW} � /''..' -7n-ilter w`q p
_ This form may be scanned and avails le for public view on the Mason County`Web site. Revise 2/7/2018
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