HomeMy WebLinkAboutWEC2023-00076 - WEC Application - 6/10/2023 •.
c,0' '�1 ` 415 N 6TH STREET, SHELTON,WA 98584
' l,,, MASON COUNTY SHELTON: 360-427-9670, EXT.400
(' { ' .s 1 COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
''y i;::-._; 4', ELMA: 360-482-5269, EXT.400
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NOTICE OF INTENT TO CONSTRUCT A WELL 1UL 1 0 2023
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Permit Number Payment Information Instructions 1. Complete Part 1. Incomplete applicati t '
Q.03witi be rejected _
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WEC Receipt Number( n•0 � 2. Attach a plot plan and vicinity map.
0 Cash 3. Submit this completed application with appropriate fee a minimum
jp1', 0 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 1/10Ig 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
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PART 1: Applicant/ Parcel Identification ZI, a' ,;_.•,ck
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53 S 3 2_Site Address a 4n/!ems AD �4 tl Start Card#
Drilling Firm 1 rA'64-e t r t)11 144 _ Phone 1� 5)O. 3''
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Applicant /4/Gh4v� 9oc a- 6! c Phone -
Mailing Address &/1-1 J)L4 A. S� n-------- q
City e L 1 AVtA State iA/A Zip / C))
Parcel Number 3 a)O 55 ) 000 12...
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Directions to Site Mc-6.0t•,r , _n__ ok/_Anvil-t A aT °A-I-L.SAG 0.) GD
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 ❑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 addit. nal fees may apply to all new wells drilled after January 19t", 2018 per ESSB 6091.
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Ap icant/A e
PART 2: Health Department Review (Staff Use Only)YES NO TAG #
Called In Ifi 3 t r
Z3 fO'ik e/C/23
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❑ .2 Driller on Site?
❑ ,,ca' Is the well capped and Vented?
❑ Is there evidence of a surface seal? Li i • 3 31 2 ji co
,❑r ❑ Is there a 2" annular space on all sides`fc2FIks �the casing? 1�3 oq o B �`�
El El Has the seal slumped? t4 4.T �$
❑ Is the well flowing or is there evidence of other leakage? Z.,
❑ , 1 Is there evidence of cascading water? O
,/ ❑ Is there evidence that the seal is at least 18 feet long? 7.---
❑ Do the well site set-backs appear to be appropriate?
Comments ( IIK.5 tlif -$K l it;( Poa 0'o l 164'fitEt. Tt. C Nkl-F fL LJ- - 2 It,ltb's lla64,01.
� ss Fail Inspector Y V /�,/;�' ,(,v� Date 4 2 3
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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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Mason County WA GIS
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