HomeMy WebLinkAboutWEC2021-00006 - WEC Application - 1/13/2021 415 N 6TH STREET, SHELTON,WA 98584
i t, MASON COUNTY SHELTON:360-427-9670, EXT.400
'ail "+ ! COMMUNITY SERVICES BELFAIR:360-275-4467, EXT. 400
,y, aY Building,Planning,Environmental Health,Community Health ELMA: 360-482-5269, EXT.400
.' .si VE>• 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 ..1,' 2. Attach a plot plan and vicinity map.
c72°a l ' Cash 3. Submit this completed application with appropriate fee a minimum
,I Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
LDate of Payment 1/13(al 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 292 E McMicken Road Shelton,Wa 98584 Start Card# WE42210
Drilling Firm Knapp Drilling Inc Phone 360-427-8174
Applicant Craig&Heidi Milanowski Phone 360-463-6111
Mailing Address Po Box 55
City Shelton State Wa Zip 98584
Parcel Number 22001-31-90032
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, Posted 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 19`^, 2018 per ESSB 6091.
�pplic /Agent Signature
PART 2: Health Department Review(Staff Use Only) r
YES , NO TAG # Called In C42 2—( (/2y I-)_(
Er Driller on Site? 111
❑ ❑' Is the well capped and Vented? 'ti -1 7_4 g a
EY ❑ Is there evidence of a surface seal? — l u, s.1 13 ck dct
❑ Is there a 2" annular space on all sides of the casing?
❑ ❑ Has the seal slumped? (4,21 c )5e-M.(E1�
❑ E3 Is the well flowing or is there evidence of other leakage?
❑ aIs there evidence of cascading water?
e ❑ Is there evidence that the seal is at least 18 feet long? '
Et ❑ Do the well site set-backs appear to be appropriate?
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Pass ❑ Fail Inspector `�� 6E ac Date 4/2-it Z I '33�y-T
j This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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