HomeMy WebLinkAboutWEC2020-00050 - WEC Application - 4/21/2020 •
"'� ';;, 415 N 6TH STREET, SHELTON,WA 98584
m,. ,'., MASON COUNTY SHELTON:360 427 9670, EXT.400
�' 'i COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
�^ ELMA: 360-482-5269, EXT. 400
'4' , ,,,/, Building,Planning Environmental Health,Community Health
-w,n; ON' 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 " [�1D7 2. Attach a plot plan and vicinity map.
o�vaG 0 Cash 3. Submit this completed application with appropriate fee a minimum
❑ Check of 24 hours in advance of initiating well construction. Refer to
C)50� ,_ Mason County Environmental Health fee schedule for cost.
c � Date of Payment f c1l`c� 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 W Chappell Crossing Start Card# WE38729
Drilling Firm Arcadia Drilling Inc Phone 360-426-3395
Applicant Sara Miller Phone 360-556-3594
Mailing Address PO Box 1790
City Shelton State WA _ Zip 98584
Parcel Number 42016-32-90&&U 400
Directions to Site See attached map.
Is the well site within 100 feet of salt/seawater? ElYes 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 restrictions and additional fees may apply to all new wells drilled after January 19'', 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# Called !n 1//P/22. Fc2 ►/201 z v
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal? \FElCSIIV CI ElIs there a 2" annular space on all sides of the casing?
❑ CIHas the seal slumped? AR 2 , 2020
El ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water? ��—�mmmo
CI CI Is there evidence that the seal is at least 18 feet long? ��" p6,®
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments A)O r I AI.i Pr c_.7
El Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018