HomeMy WebLinkAboutWEC2021-00007 - WEC Application - 1/13/2021 l�" 415 N 6TH STREET, SHELTON,WA 98584
„ MASON COUNTY SHELTON: 360-427-9670, EXT.400
'11 'n,' COMMUNITY SERVICES BELFAIR:360-275-4467, EXT. 400
ELMA: 360-482-5269, EXT.400
r 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 I ....a f 2. Attach a plot plan and vicinity map.
ON �1 [ _ Cash 3. Submit this completed application with appropriate fee a minimum
O� y� Check of 24 hours in advance of initiating well construction. Refer to
G� Mason County Environmental Health fee schedule for cost.
G Date of Payment (I13�� 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification
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McMicken Road W -
Site Address 318 Start Card#
Drilling Firm Knapp Drilling Inc Phone 360-427-8174
Applicant
Joel Stenersen Phone 360-263-5104
Mailing Address 33803 Winter Creek Road
City Yacolt State Wa Zip 98675
Parcel Number 22001-31-90021
Directions to Site Out to Harstine Island,turn right after bridge,go 3 miles to the T,turn left,go just over a mile to McMicken on right,
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.
At0:1AP
AlicanttrAgent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG #
Called In 44 2 3/"2_i r' 11 2 l
❑ ❑ Driller on Site? 1/ti2A reik, 1Iatz_l
❑ ❑ 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?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ 0 Do the well site set-backs appear to be appropriate? T J 06_ -P.9-t IAT D ftRty' '
Comments {>u�n.T tr �7�� ��`r VAlc`lY. x►441 er c.ku.ts-•�Iz3 ) • fgr tit5iN�c-��
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❑ 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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Sources Esn,HERE.Garmin.Intermap,increment P Corp.,GEBCO.USGS,
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