HomeMy WebLinkAboutWEC2024-00022 - WEC Application - 2/9/2024 MASON COUNTY 415 N SHELTRON:360,427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467,EXT.400
ELMA:360482-5269,EXT.400
FAX 360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
���y���rr� ��''���r�ra 1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Numb9aQN_L/% 2. Attach a plot plan and vicinity map.
!y"(11 t ryy n�1 �7 Cash 3. Submit this completed application With appropriate fee a minimum
�AN�✓� ¢ Check of 24 hours in advance of initiating well construction. Refer to
_ Mason County Environmental Health fee schedule for cost.
Date of Payment Lk4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification
Site Address I--o t 3 O t-h'j It� (,5 ke�{z.start card# till) E
Drilling Firm AkAn ed D.-;(Ir14( LLL Phone 366 :2:23-�1135—
Applicant P L Phone 36a 4116 -qS jq.
Mailing Address ao I L4" to 15 W
city IQ a r,G.e t{Z✓ state W,+ Zip 4 Ss ) `j
Parcel Number A- .-.wtCon
!� K,J/ U ba 0000 /�
Directions to Site •J Ski.lion I'I`'A6L G6 AA ICh +15 W HkIllif nd U. COIoh o !x
Is the well site within 100 feet of salt/seawater? ❑Yes f9No
If yes, a variance from DOE is required.Have you applied/received(circle one)a variance? ❑Yes ❑NO
NOTICE:Asproposedcomreegarsfonnvw are Srtycc wa adequacyregefrementSattimeofd lWd pemsfper Masan Cow4yT 6.69.
Wafe/r�s�ge restrics sand eCEebnaltees meyappy to as net,wags dried after January W. 2e18per ESSS 6091.
f a r"T
Appli nt/Agent Signaturov
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# S Calledin bj121L1 rm OBe IN �14
❑ �' Driller on Site? 2. pulls , Pr"P
[ ❑ Is the well capped and Vented? 1(.
❑ Is there evidence of a surface seal? Lr +� 'Lp 5 T t
❑ Is there a 2"annular space on all sides of the casing?
❑ Has the seal slumped?
❑ a Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
Comments
�(J Pass El Fail Inspector pU ` � Date (P Ly
/ This form may be scanned and available for public New an the Mason County Web oft Revised:2/7/2018
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