HomeMy WebLinkAboutWEC2021-00167 - WEC Application - 8/30/2021 \•, MASON COUNTY AUG 3 ''r415 N 6TH STREET, SHELTON,WA 98584
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SHELTON:360-427-9670, EXT.400
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4 ?; COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
\\t%�`.a>ri/, Building,Plammnq.Environmental Health,CommumryHealth J " '•�� ELMA: 360-482-5269, EXT.400
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 2. Attach a plot plan and vicinity map.
�o a ❑ Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
CDC' kin Mason County Environmental Health fee schedule for cost.
Date of Payment 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 251 PE SowAG Jc-i- Lt Start Card # WC t J5 Toy
Drilling Firm 0yc.oA;c� -D�,\V&-,Q� �tnc. . Phone 3(oc- 2 o-33ci5
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Applicant E11vvvtAgo Phone 3(po- Slc - 321-1 I
Mailing Address Pa goc t 1 QO
City S1/4QIAOv\._ State Lc-. Zip qES `t
Parcel Number 322 t2- `7 to- Oo 120
Directions to Site 781)
Is the well site within 100 feet of salt/seawater? ❑Yes ONo
If yes, a variance from DOE is required. Have you applied / received (circle one) a variance? ❑Yes [2i(o
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 u age restrictio 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 ' 14 I2Z Feria t(I 12z_
❑ ❑ 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? r-
❑ ❑ Has the seal slumped? C.
❑ ❑ 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? c>
❑ ❑ Do the well site set-backs appear to be appropriate? ,�
Comments tic T 11,4,c'l i._-t-Q" -I
ElPass ❑ Fail Inspector Date c
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This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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