HomeMy WebLinkAboutWEC2023-00044 - WEC Application - 4/28/2023 /°�L 415 N 6TH STREET,SHELTON,WA 98584
F,, MASON COUNTY SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
'41y �y� euildutg.PlarmingEmironmentai Health,Community Health
u,. I INI' 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.
3 /y�l�lJ ❑ Cash 3. Submit this completed application with appropriate fee a minimum
`'I `fir Check of 24 hours in advance of initiating well construction. Refer to
1 / J Mason County Environmental Health fee schedule for cost.
L
Date of Payment l 23 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant 1 Parcel Identification
Site Address 101 E Forest Estates Start Card# WE52535
Drilling Firm Advanced Drilling LLC Phone 360 273-7735
Applicant Kalin Somero Phone 360 280-2867
Mailing Address 101 E Forest Estates
City Shelton State WA Zip 98584
Parcel Number 4=ii44#29 3 a I to a 3 co 6730
•
Directions to Site Hwy �p �L/(�G�Y . l_st 4C.e- rid I i- C•t U�` L 1-7Ov-z 51- 6-5•1
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:A p osed nnect s to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
ater us re fiction and dd anal fees may apply to all new wells drilled after January 19'h, 2018 per ESSB 6091.
Applicant/A nt Signature
PART 2: Health Department Review (Staff Use Only) /
YES NO TAG # Called In (>'f l 2 J7_ t-ef 6/t3
❑ 2' Driller on Site? 111
❑ Is the well capped and Vented?
17( ❑ Is there evidence of a surface seal? (� M
,1Z1— ❑ Is there a 2" annular space on all sides of the casing? D lI U
❑ ,� Has the seal slumped? U
❑ J� Is the well flowing or is there evidence of other leakage? APR 2 8 2023
❑ 12 — Is there evidence of cascading water?
❑ ❑t"-Is there evidence that the seal is at least 18 feet long? By
_' ❑ Do the well site set-backs appear to be appropriate?
Comments
❑ Pass ❑ Fail Inspector f f,( ,- Date {o/f`f(2-3
This form may be scanned and available for public view on the Mason County Web site. Rcviscd:2/7/2018