HomeMy WebLinkAboutWEC2020-00112 - WEC Application - 7/4/2020 MCM1V
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C fri 5 N 6TH STREET, SHELTON,WA 98584
` MASON COUNTY q SHELTON: 360-427-9670, EXT. 400
,1111111131 COMMUNITY SERVICES :Y: ,j,,,,4 2020 BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Building,Planning,Environmental Health,Community Health
FAX: 360-427-7787
BY:
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
n/ 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number AO' I-LV 2. Attach a plot plan and vicinity map.
El Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
Od 11 _ Mason County Environmental Health fee schedule for cost.
Date of Payment z /lea 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 110 E Mason Lake Dr S Start Card# WE39978
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Dave Smith Phone 360-580-6905
Mailing Address PO Box 1790
City Shelton State WA Zip 98584
Parcel Number 22108-50-00011
Directions to Site See attached map.
Is the well site within 100 feet of salt/seawater? ElYes No
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? [Wes 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.
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:Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In (a13 f Zt (014 2-1
❑ ❑ Driller on Site?
❑ ❑ ` 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?
❑ El Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ El Is there evidence that the seal is at least 18 feet long?
❑ El Do the well site set-backs appear to be appropriate?
Comments V Joi 1/f SF�G
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018