HomeMy WebLinkAboutWEC2021-00118 - WEC Application - 5/27/2021 ICIEUV + 15 N 6TH STREET, SHELTON,WA 98584
..*:if MASON COUNTY SHELTON: 360-427-9670, EXT.400
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'11' COMMUNITY SERVICES NAY 2 ? 2921 BELFAIR: 360-275-4467, EXT. 400
,, _:_�- ELMA: 360-482-5269, EXT.400
.,, Building,Planning,Environmental Health,Community Health FAX: 360-427-7787
BY:
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
��/Q' 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt NumberR )'c` g 2. Attach a plot plan and vicinity map.
afal, C !�' 0 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment E, IVI 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 100 Coon DR N Start Card# WE44212
Drilling Firm Nicholson Drilling Phone (360)876-4421
Applicant Greg Barich do Nicholson Drilling Phone
Mailing Address PO BOX 123
City
Port Orchard State WA Zip 98366
Parcel Number 22224-75-900 Isr,oifZ
Directions to Site North of E Crest DR on E Coon DR N
Is the well site within 100 feet of salt/seawater? ❑Yes No
If yes, a variance f • DOE is required. Have you applied/received (circle one)a variance? ['Yes ®No
N• . ,I •ropose, nections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
, ater u•-ge -stricti. - d additional fees may apply to all new wells drilled after January 19`",2018 per ESSB 6091.
4 ��'
44111-11".-- °pp a t/Agent Signature
2: H•alth Department Review(Staff Use Only)YES NO TAG# a K - t, (,'7 Called In 48// /Zt Th/2 g(Zy//
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GI, ❑ nller on Site? 2,014 iel`'t•tb f
❑ L 1s the well capped and Vented?
1E2,- ❑ Is there evidence of a surface seal?
0 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?
❑ 2 Is there evidence of cascading water?
12/ El Is there evidence that the seal is at least 18 feet long?
El Do the well site set-backs appear to be appropriate?
Comm nts 4i.3t3:Y - , _ 12,a •Vc19 a-L ,"a' 1'Y bps
ass ❑ Fail Inspector Date $,n1).t
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018