HomeMy WebLinkAboutWEC2023-00014 - WEC Application - 1/30/2023 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
ELMA:360-482-5269, EXT.400
Budding Planning.Environmental Health.Commundy Health
FAX:360-427-7787�p
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NOTICE OF INTENT TO CONSTRUCT A WELL
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Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications Biyx.tgjgatgd
WEC Receipt Number )23-0054.2 2. Attach a plot plan and vicinity map.
Zi%_O0��yy ❑ Cash 3. Submit this completed application with appropriate fee a minimum
`4� Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 1/1)D,1) 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 X X K ?- N,7s re Start Card# 4.)
Drilling Firm ,G/c-r.�lDvr, / , // ��,, //r ‘ • Phone ,2 3 -S3T- 7�3�
Applicant A; Phone 025 3 yOS'?v 2�j
MailingAddress �r�
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City "G-co1-,- q State /ply . Zip Si- 9i-/
Parcel Number Z2'03-/y- 9p7SV
Directions to Site 1JT'n c ,di74c % ? fD
27,‘, 4 -7,); 7- • e_ yv A0,,
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 strictions and additional fees may apply to all new wells drilled after January 19'", 2018 per ESSB 6091.
pplicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# Called In 211 L/L3 Foe 2/22./2 3
❑ ❑ 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?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments Afpf fArSPgGT--t.
❑ 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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