HomeMy WebLinkAboutWEC2023-00082 - WEC Application - 7/20/2023 0
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.0:°` x, : 415 N 6T"STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
.'. �� COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
` ELMA:360-482-5269, EXT.400
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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.
2-122-S— 0 Cash 3. Submit this completed application with appropriate fee a minimum
.D Check of 24 hours in advance of initiating well construction. Refer to
'Q 8 2_ Mason County Environmental Health fee schedule for cost.
Date of Payment 't f ZO`Z 3 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
Site Address 0 Kamilche Lane Start Card# WE52706
Drilling Firm Advanced Drilling Phone 360 273-7735
Applicant Earl Smith Phone 360 426-4499
Mailing Address 3161 E Brockdale
City Shelton 9 CO 2 State WA Zip 98584
Parcel Number 31907-44-9$642—
Directions to Site 1001 Kamilche Lane, follow fence on the north side of property to site on left _
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 lime of building permit per Mason County Title 6.68
(Water age restrictions nd additional fees may apply to all new wells drilled after January 19'".2018 per ESSB 6091.
Appli nt/Agent igna re
PART 2: Health Department Review(Staff Use Only)
YES NO TAG # Called In `712-t '2_ Fatz-.. ?I L`f/2-
❑ Driller on Site?
❑ ,2'" Is the well capped and Vented? f y- 3 J- Z 3
❑ ❑ Is there evidence of a surface seal? N•0• 4 7
❑ ❑ Is there a 2" annular space on all sides of the -asin ? 1J•0. _ t 2 3• O4 g t 1 1
❑ ❑ Has the seal slumped? C! CB` aVc; M• v
❑ ❑ Is the well flowing or is there evidence of other leakage? fJ. O•
❑ ❑ Is there evidence of cascading water? t J• D•
❑ ❑ Is there evidence that the seal is at least 18 feet long? AL O .
X ❑ Do the well site set-backs appear to be appropriate? _j,
Comments Dnl//erSdKstso 12"1,. .4... 1 t Inks eh -fri4
Pass ❑ Fail Inspector ryA(4‘01 Date 7/ZY(t
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This form may be scanned and available for public view on the Mason County Web site. Re iscd:2/7 201t
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