HomeMy WebLinkAboutWEC2021-00155 - WEC Application - 8/3/2021 \ 415 N 6TH STREET, SHELTON,WA 98584
/ y\ MASON COUNTY SHELTON: 360-427-9670, EXT. 400
COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
ELMA: 360-482-5269, EXT.400
Building.Plannmg.E nviron mental Health.Community Health
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 al q tteDa 2. Attach a plot plan and vicinity map.
o;CDQ-l _ ❑ 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.
OO 155 Date of Payment 13 1 ai 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 520 NE Dewatto RD Start Card# WE43365
Drilling Firm Nicholson Drilling Phone (360)876-4421
Applicant Zach Jones Phone
Mailing Address c/o Nicholson Drilling PO BOX 123
City Port Orchard State WA Zip 98366
Parcel Number 32335-50-00020
Directions to Site Northwest of NE Tee Lake on NW Dewatto
Is the wel site within 100 feet of salt/seawater? ['Yes ❑No
If yes, a v riance fro DOE is required. Have you applied / received (circle one) a variance? ❑Yes ❑No
NOTICE:AI roposed c nections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
er u ag restrictions nd additional fees may apply to all new wells drilled after January 19'. 2018 per ESSB 6091.
licant/Agent Signature
2: H alth Department Review(Staff Use Only)
NO TAG # Called In 2 I2-2 2-
S
❑ ❑ Driller on Site? Po�cv�
❑ ❑ Is the well capped and Vented? 2 13I 2-2- F°"2 244 122-
❑ ❑ 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 (�f+' t N'r-'e e-
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/20 1 8
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