HomeMy WebLinkAboutWEC2021-00003 - WEC Application - 1/6/2021 „,,,,,,I,;'' 415 N 6TH STREET,SHELTON,WA 98584
r ;:, MASON COUNTY SHELTON: 360-427-9670, EXT.400
„ -; �l' - COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
E L MA: 360-482-5269, EXT.400
;% ,,„d` Building,Planning,Environmental Health,Community Health FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
0G'C 1. Complete Part 1. Incomplete applications will be rejected
WIC_ Receipt NumberJ 2. Attach a plot plan and vicinity map.
,Jk/1 1�111311 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
r� �1 / , Mason County Environmental Health fee schedule for cost.
V d b 03 Date of Payment 144�� 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 140 E country Bumkin Lane,Shelton Wa 98584 Start Card# WE42117
Drilling Firm Knapp Drilling Inc Phone 360-427-8174
Applicant Thomas&Barbara Wilderbuer Phone 360-427-3206
Mailing Address 60 E Country Bumpkin Lane
City Shelton State Wa Zip 98584
Parcel Number 22012-23-90080
Directions to Site Out to Harstine Island , turn right after the bridge,go 3 miles to the T, Tum Left,Country Bumkin Lane is just over
0.5 miles down on the right, Black gate go through,down to the end.
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? EYes ®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 19ih, 2018 per ESSB 6091.
Apple t/Agect.....ignature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG # Called In Ofi'f L! (pa SO (2-(
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented? (� (� _
❑ ❑ Is there evidence of a surface seal? h M l r s rat
❑ ❑ Is there a 2” annular space on all sides of the casing? I
❑ ❑ Has the seal slumped? JAni (} 'J zuL i 11`
❑ ❑ Is the well flowing or is there evidence of other leakage? L
❑ ❑ Is there evidence of cascading water? By_4,
�..
❑ CI Is there evidence that the seal is at least 18 feet long? ._+
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments Al r 11 S PEc,DE
❑ 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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M. Halverson Design LLCSite Info:140 E Country Bumpkin Ln ��`zER
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Si Thomas & Barbara
PO Box 1519 Shelton Wa 98584 Shelton,WA 98584 7Wilderbuer
(360)490-6365/hatversondesign(ic@outlook.com parcel#: 22012-23-90080 ,.