HomeMy WebLinkAboutWEC2023-00055 - WEC Application - 5/23/2023 f
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`: 415 N CH STREET SHELTON,WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
l� COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
--r ELMA: 360-482-5269, EXT.400
Building,Planning Environmental Health,Community Health
FAX: 360-427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Numbera.5- 1 4 0 2. Attach a plot plan and vicinity map.
0 a3 ❑ Cash 3. Submit this completed application with appropriate fee a minimum
i 0 Check of 24 hours in advance of initiating well construction. Refer to
/� Mason County Environmental Health fee schedule for cost.
y D� Date of Payment s1 vs)23 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 1500 E Mason Lake Rd Shelton, WA 98584 Start Card# (JLi 6Z-�Ma
Drilling Firm Moerke & Sons Phone 360-748-3805
Applicant Christopher Gaynor Phone 360-990-2881
Mailing Address 1500 E Mason Lake Rd
City Shelton State WA Zip 98584
Parcel Number 32134-23-90020
Directions to Site Fron Shelton:North on SR 3,Left on Mason Lake Rd,travel approximately 1.5 miles,green gate on right side(Gate Code 1937)
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 time of building permit per Mason County Title 6.68.
Water usage rests s and additional fees may apply to all new wells drilled after January 19t^,2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# Called In :.s;LS cik ILL I L'
❑ Driller on Site?
❑ ...2- Is the well capped and Vented? 4-1 .-zr',:sa
❑ - l i3 cSbl 2'3 __---------`tl r�
�^ Is there evidence of a surface seal? (� (� I�
❑ Is there a 2" annular space on all sides of the casing? rt� ty
❑ Has the seal slumped? �;
MpY 2 3 2023 \---
❑ a Is the well flowing or is there evidence of other leakage?
Cl ❑/' Is there evidence of cascading water?
El Is there evidence that the seal is at least 18 feet long? BY
ja— ❑ Do the well site set-backs appear to be appropriate?
Comments t 0 Ab 1 il, 1ootI a1%N"..:15-- i".- ;-LA. rt, 018 SL✓'_co 4.,2_,_.-Q-
lass ❑ Fail Inspector /1AMA_ Date SIZE()-3
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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