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HomeMy WebLinkAboutWEC2021-00033 - WEC Application - 2/2/2021 + \ 415 N 6TM STREET,SHELTON,WA 98584 j 1 MASON COUNTY SHELTON: 360-427-9670, EXT.400 r 1: COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400 ' `: ' , qy; `" . Building,Planning,Environmental Health,Community Health ELMA: 360-482-5269, EXT.400 Wit,.^ 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 a t -1,I I 2. Attach a plot plan and vicinity map. �a l ❑ 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. 3 Date of Payment a12( 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. — — -- , PART 1: Applicant 1 Parcel Identification 2t0 C- Site Address Nearest to 1.2-E Appaloosa Dr, Shelton, WA, 98584 Start Card# WE42433 Drilling Firm Knapp Drilling Inc Phone 360-427-8174 Applicant Robert Balcom Phone 360-427-8174 Mailing Address 852 172nd Street E City Spanaway State WA Zip 98387-7714 Parcel Number 22001-33-92004 Directions to Site North on E Harstine Island Road N, Right on E Appaloosa Dr, about 185ft down on the 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 ells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68. Water usage restrictions and additional fee ay apply to all new wells drilled after January 19th, 2018 per ESSB 6091. Applican\ ,gent SigiLLe PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In frik(2 1 :DI Gi 9 j 2- I ❑ Er Driller on Site? ❑ Is the well capped and Vented? u ❑ Is there evidence of a surface seal? Er ❑ Is there a 2" annular space on all sides of the casing? '". ❑ l�4 � � Has the seal slumped? ,� 2n��� -� ❑ a Is the well flowing or is there evidence of other leakage? .�a ❑ ET Is there evidence of cascading water? __ ❑ El Is there evidence that the seal is at least 18 feet long?►J© v ..-- ..— a ❑ Do the well site set-backs appear to be appropriate? Comments 2`{ 4�'vc �4-6C 1(�'LS&-ez � i 7 t ni�?v etEcr(�i c_ Inspector /��'ti � �� Date f [_4 2-I s ❑ Fail rk j , / This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 f 9 1 01. ,,......„ 1 1 i R V 1 7. (-7 r• i / 0 V.,...-----3 (-----As H1jtt 1 -n3 M -14 dik ?..,,,c04 4, .. % 4 --X4 ----7 „ v. . -ho Cr?b E c / og-zz r -7,3--)--iited