HomeMy WebLinkAboutWEC2023-00124 - WEC Application - 10/10/2023 MASON COUNTY 415 N 6TM STREET,SHELTON,WA 98584
SHELTON:360427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:380-276 4467.EXT.400
ELMA:3604825269,FACT.400
FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number P9ymeM lMormatlon Instructions
1, Complete Part 1. Incomplete applications will be rejected
qq WEC Receipt Number Zj - 2. Attach a plot plan and vicinity map.
eL0 15 0 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
VZ Mason County Environmental Health fee schedule for cost.
( Date of Payment 1 O. I V" 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant/Parcel ItlentlRcatlon
Site Address 3Z.5 LJ H15HLANO Al Ls Pa 515LTOI) WA Start Card# SSr2-1
Drilling Firm RoFR g A, n pump X Del a INC Phone 3�f o,ly g,$gnS
Applicant D^N,e:Lue P^VYtAew: DHv N P vM(5PrT Phone 360.701,3107: 463.7SF�
Mailing Address -1510 ■ U) StiELlDM MATLOGk Rn
city S4ELTo e) State UA Zip q988-1
Parcel Number 52.O74v 3QOD111
Directions to Site 4iu,4+n Me+Ar I, Dcj T...- L eMe Hq tonA tta: 2.mi 1,,m a .s6N"�1.I d N-II
of F-II 4..-, L onho 5t....ad I� way -pw 7_ ry,i�nn s, -tM°4 k {Cntal ar M. Arn Je..
Is the well site within 100 feet of salt t seawater? []Yes ®No
If yes, a variance from DOE is required. Have you applied f received (circle one)a variance? ❑Yes []No
NOTICE:Alfproposedowmechom to new"Its are subject to wafer adequacy requirements at rime ofbuib g permit per Masan County Tfik 6..68.
Waterusage msinobans anted add'iaona/fees�mayapp/y to a8 new,wetiss ditt8ed after January 19°,2018 per ESSB 6091.
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Ap Icant Agent Signature
^r�iEhy,E. Pnvh c" 0evn.1 p^vM=Nr
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# B6F4 S1`f Called In ZIf 6121?
❑ .a- Driller on Site? 3 -17_3 . 2W0T71
O ❑ Is the well Capped and Vented? 47, zooM SI r
Er ❑ Is there evidence of a surface seal?
,Y ❑ Is there a 2"annular space on all sides of the casing? D D
❑ -0 Has the seal slumped?
❑ El— Is the well flowing or is there evidence of other leakage? l)�I 0 9 2023
❑ JM- Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?'Klarnlac-ved
❑ a- Do the well site set-backs appear to be appropriate?
Co ants
Pass [] Fail Inspector rEX4 Date
This Arm,may be scanned and available for public view an the Mason County Web site. Revised:2/7/2018
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