HomeMy WebLinkAboutWEC2022-00157 - WEC Application - 11/3/2022 T-• • ,.
J` G.�t,;y 415 N 6TH STREET,SHELTON,WA 98584
�" "s, MASON COUNTY SHELTON: 360-427-9670, EXT.400
TY SERVICES BELFAIR:360-482- 6 , EXT.400
'1-4, � COMMUNITY ELMA: 360-482-525269. EXT.400
v " .. w,Jdin Planning' rnvua„nental Health.Community
ury tl FAX.360-427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
_---------
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 2. Attach a plot plan and vicinity map.
2-0 ZZ— 0 Cash 3. Submit this completed application with appropriate fee a minimum
----- O Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
co k 5 1 Date of Payment t,lgIZL 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification y t t .7 .4
1. Site Address 3n W , Q C.0 't V l I�
��j t Plc a Start Card # Vi£ 67k
Drilling Firm (qc__,‘ ev_r_C1t ('�. 2-S i Phone c Z 9-�f Q 53q
Applicant t`k t C_.-\- ck kANa 1a P l C/e(AV e 4) Phone o�412..610^`t \3 1'a1 C
�1.v" 1
Mailing Address al A ( —n' ;Q, f`
City ab LP a,tt..tt/1 State\Ai q Zip ci 1?) ,_0
Par Number fIz1)-7 pU � ` (�1
Directions to Site-i'4N_. Sh�l-ton-HAIV t f� 1"1Q �?.CI'._ ... c Qf vi'Ik ru, '�-
v./ . OQc—.Y-,Z N V t\ c? � -t-o
is the well site within 100 feet of salt/seawater? ❑YesC]No 33
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 addrtronal tees may apply to all new wells drilled after January 19m, 2018 per ESSB 6091.
rn(),A,*(Aift- Th , 4
plicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)•
YES NO TAG # Called In % 2-//2--/ 22._
Er ❑ Driller on Site?
❑ ❑' Is the well capped and Vented?
„La' ❑ Is there evidence of a surface seal?
Zi ❑ Is there a 2'annular space on all sides of the casing?
❑ ❑ Has the seal slumped? ti(c'r t, Sf=7-1/Vt
❑ •' Is the well flowing or is there evidence of other leakage? yC I
❑ -Is there evidence of cascading water? / 7 . Z 13! "•
❑ Is there evidence that the seal is at least 18 feet long? ---(;5 . 4 csb 4 f
T ❑ Do the well site set-backs appear to be appropriate?
Comments /c b4�r 9 ie yAP r
(] cA f 1rr-0-t.
'Pass ❑ Fail Inspector /
r.
_._ Date — /2 I f 4/ I y.
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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