HomeMy WebLinkAboutWEC2019-00082 - WEC Application - 7/18/2019 ,.
? `�' rit 415 N 6T"STREET, SHELTON,WA 98584
J ;,, MASON COUNTY SHELTON: 360-427-9670, EXT.400
'7 'l l' F . : COMMUNITY SERVICES BELFAIR:360-275-4467, EXT. 400
• ..r iii ELMA: 360-482-5269, EXT. 400
1/4 Building,Planning,Environmental Health,Community Health
•1,.tr_r�'. 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 /CI' 61- 5 2. Attach a plot plan and vicinity map.
Dom/V1Pt. D Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
000 Q�� Mason County Environmental Health fee schedule for cost.
v Date of Payment �I1$in 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 591 E Big Skookum Start Card# WE36036
Drilling Firm Arcadia Drilling Inc. Phone 360-426-3395
Applicant Paul Bailey Phone 360-731-3605
Mailing Address 3139 SE Beach Crest Court
City Port Orchard State WA Zip 98366
Parcel Number 22020-75-00190
Directions to Site See Attached Map kCertf p- tit :i -f l k % . a rS. ft.-r1 ,.i t_F' , FS 1t6A-l,t„ IXN. i-r
, a Al S Ies- S( 3 O r—0 Ms, qy{�
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 restry
nd additional fees may apply to all new wells drilled after January 19', 2018 per ESSB 6091.
nt/Agent Signature k .- VTVTR
PART 2: Health Department Review (Staff Use Only) C, JUL 1 7 2019
YES NO TAG# Called In 2 /t Z—
2-- y _,Ei Driller on Site? • ��--__
❑ Is the well capped and Vented? ISlZZ C`��� J'M
PAK ❑ Is there evidence of a surface seal? 5 I t SVZ •.e-c-at Is there a 2" annular space on all sides of the casing? S"(1(aI,LL-
❑ .E' Has the seal slumped?
❑ f 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? ISO i egg -itj�
❑ Do the well site set-backs appear to be appropriate?
Comments 41. Zol,4S1 , - (21 AO SSA
ass ❑ Fail Inspector Date S"l/7I LL
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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