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HomeMy WebLinkAbout_WEC2024-00066 - WEC Application - 5/29/2024 415 N 6TM STREET,SHELTON,WA 98584 MASON COUNTY SHELTON:360427-9670.EXT.400 COMMUNITY SERVICES BELFAIR:360-275.4467,EXT.400 ELMA:360482-5269,EXT.400 FAX:360427-7787 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. ❑ Cash 3. Submit this completed application with appropriate fee a minimum arL �O W Check of 24 hours in advance of initiating well construction. Refer to Mason County Environmental Health fee schedule for cost. Date of Payment 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the wall. PART 1: Applicant/Parcel Identification f G y 2 Site Address �i , i�-1'(— LA� A Start Card# W F S Drilling Firm DIA.V r ( rl IV-!I/ Phone 30'Z.7S Sr-3 7 Applicant _SAW Phone Mailing Address u' 40 Nifft :3#� L14 City —TAywis ti State WoD— zip Parcel Number 7> -0090 Directions to Site 'From bCM1Q4o irAu N r -Tee u kt- �-L— 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 �INo NOTICE arproposed conneaboms to new weMa any subject to wateradequacy mqulrwnents at time ol6uilding pemvt per Meson Counly rite ads.. Water usage reslrkfbns and addWonal fees my apply fo a9 new wells untied aler January IQ-,2018per ESSB 6091. Applicern/Agent Signature PART 2: Health Department R"Iew(Staff Use Only) � YES NO r TAG# Called In 3',f1/i'(• Fm p ❑ Driller on Site? ❑ Is the well rapped and Vented? LAr: q.a �t3s6`l p ��-�yjs- ❑ ❑ Is there evidence a surface seal? Loki(& +-IL3, OLl(0 = ❑ Is there a 2"annular space on all sides of the casing? ❑ Has the seal slumped? G ❑ 5T Is the well flowing or is there evidence of other leakage? ❑ Is there evidence of cascading water? .p ❑❑❑ Is there evidence that the seal Is at least 18 feet long? ❑ Do the wall site set-backs appear tQ be appropriate? Comments o: ^' '� pass ❑ Fail Inspector l Data T This form may be scannetl and available for public view on the Mason County Web site. Revised:W/2018 \EEIAKEROAD mi§74op j NEIGHBORING WELL RIOp,� 1 11 1 R35 /� i j I PROPOSED DRAINFIEL / TRANSPOR LINE 50'+ FROM VN' POSSIBLE , �. / • ��FVT APPROVED l/RE WELL / ` / �1 � r \�� PROPOSED NUWATER MAY 1 i Ml i1 R5o & PUMP TANK MASON COUNTY ENVIRONMENTAL HEA EXISTING I 23N , Wi S3SDJA J CABIN APPROXIMATE s�/ Is E EDGE OF LAKE >-_� ,