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HomeMy WebLinkAboutWEC2020-00199 - WEC Application - 12/17/2020 415 N 6TH STREET,SHELTON,WA 98584 SHELTON: 360-427-9670, EXT.400 1` .. '� ll.-;,, MASON COUNTY i COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400 V�a Building,Planning,Environmental Health,Community Health ELMA: 360-482-5269, EXT.400 % FAX: 360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information Instructions �C�, 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number S/Ite_`S 2. Attach a plot plan and vicinity map. O(0a° — 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 66 Mason County Environmental Health fee schedule for cost. Date of Payment ��I') 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 11 E Johns Creek Start Card# WE41989 Drilling Firm Knapp Drilling Inc Phone 360-427-8174 Applicant April Campbell Phone 360-490-8441 Mailing Address 201 SE Weston Road City Shelton State WA Zip 98584 Parcel Number 32005-24-00000 Directions to Site Out Johns prarie to Johns Creek, first left along the fence,easily seen in field 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 usa e restrictions and additional fees may apply to— wells drilled after January 19th, 2018 per ESSB 6091. 49 Applicant/Agent Signatuu PART 2: Health Department Review(Staff Use Only) YES NO TAG # Called In 1II2-14( i=sR li(I 3 (Zt LT❑ ❑,- Driller on Site? -1 7, Z 5-1 7 3 8 411 Is the well capped and Vented? _ t 23 ro9 ( _20 Of ❑ Is there evidence of a surface seal? X3oT oir-,50140> [ v ID 'o Is there a 2" annular space on all sides of the casing? 1- T o ) 46 `In ipC ,Mc E yam c—. ❑ ❑ Has the seal slumped? t�o"r o'6S.t�v CM V D ❑ ❑ Is the well flowing or is there evidence of other leakage? ISlbiSk�6'7 :., DEC 1 7 2020 ❑ ❑ Is there evidence of cascading water? IS,-` i*s T6 ❑ ❑ Is there evidence that the seal is at least 18 feet long?t3p-`ogs vela BY: Ltd ❑ Do the well site set-backs appear to be appropriate? l Comments STAR'rf12 Gk►4 (go c_RSIKG tit-r) YEc.T 5-S, ►.oGATn't 4litn t-D - MDf6t A10,4.' Pass ❑ Fail Inspector�a� Nc(1Silliakziti lt,L _ ws. Date `///31L1 E ?�4?,D , Nio 6 1Vi >t- CE DC 40-ue 1 s•t7-I146- This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 i2 s i i A A.