HomeMy WebLinkAboutWEC2021-00193 - WEC Application - 10/7/2021 li
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OCT 0 r 2021
415 N 6TH STREET,SHELTON,WA 98584
rf` MASON COUNTY BY:___ SHELTON:360-427-9670,EXT.400
t J ui l;• COMMUNITY SERVICES - BELFAIR:360-275-4467,EXT.400
�h_ ELMA:360-482-5269,EXT.400
\,,,: ;, Bacing,P nnb,g.En*i,merdxeehhcornmtmityHealt FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information In&tructlons
1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number 2. Attach a plot plan and vicinity map.
a` 0 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment��'��' 4. Mason County Public must receive notification at least 24 hours
I s-as,-I prior to the drilling of the well.
PART 1:Applicant/Parcel Identification PJA 9$526'
Site Address ,S/ NE M�«►.1 T/+(,v LAIC I- OIL L j Q Start Card# WE46348
Drilling Firm t\I,cN4)L-5cl,� Dai( I i,3( - Phone 3/00 $ -Cr, - 44Z/
Applicant pip x Phone 31 (020-`I$9C
Mailing Address ,31 k!) 0 Ma ,„`, ,U-1-1, i L-, P}.t<,E- 70 R
City -- ,.--Li:-,.. , P- State 1,,J A- Zip 8 2,8
Parcel Number / 2 3 05 - I ( -c,v C 4 I
Directions to Site / s r I-.k;,,�,s C d.r 1Yl 1 N L.K Do_ o-f rc -T}C.1 G ,Vv7 i-_S i a.,
Is the well site within 100 feet of salt/seawater? ❑Yes to
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 am subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
ater age restric,ins •nd additional fees may apply to all new wells drilled after January 191",2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In `1 to/ Z Z Fc-,2 1t Z12-Z-
❑ ❑ 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? 7
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ D Is there evidence that the seal is at Ieast 18 feet long? ll'i
❑ 0 Do the well site set-backs appear to be appropriate? 1'
Comments — Id)c �NSPCcc-r 1\
❑ Pass ❑Fail Inspector Date 0
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This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 T
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