HomeMy WebLinkAboutWEC2024-00021 - WEC Application - 2/4/2024 ar_r
415 N 6m STREET,SHELTON,WA 98594
MASON COUNTY SHELTON:36D427-9670,EXT.400
0 COMMUNITY SERVICES BELFAIR:360-275-4467.EKE 400
ELMA:360-482-SM, EXT.400
aasga.� sr•,.o...r+n.xn.ca....wr Wry FAX 360427-7767
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavm at Intormallon Instructions -
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 2. Attach a plot plan and vicinity map.
�O ❑ Cash 3. Submit this completed application with appropriate fee a minimum
) I-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 drierg of the well.
PART 1: Applicant I Parcel We"!Pce"on
Site Address 1^O+-KSo W1-4,+ { Jk(4nd F,ocl_ tan Card# WC-554a.7
Drilling Firm Aduu uned ln(LaA LLL Phone 36e 790-7373
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Applicant Di,Alf Pfa, fiyS L1- L Phone RGa 41`10-g5vf
Mailing Address 11 'f-30 5 C�0 1 LAA,0? fU SeJ
city Kot' a6w Wit state X zip 4 ? .
Parcel Number 6 IOBv7lrbmII �IeOJ _F_ LL l�J I�2�1"�1��dd OO
Directions to Site uj %L 7J— Nle�cL [fS -� mi -� u l-flab& .e V- -s14�an �[ '
Is the Well site within too feet of wit/seawater? Oyes IpINo
If yes, a variance from DOE is required. Have you applied 1 received(arde one)a variance? []Yes ONO
NOTIC .ABgopaaedconnecAmstorwwwelsa wbjc'crroWateradcquwyrepri�arfimedbu#dRVpemr PWMason C-U-1YTle6.68.
Water res eW addldooe rees may appyto all crew wefts dY/ad suer January 19^,2018per ESSB 6091.
App nt l Agent Signa�—
PART 2: Health Department Review(Staff Use Only) ++
YES NO TAG# LPN 057 Called In 6ItZI/Ly Gb2 1, r5oP. lH�2-4
❑ ,a Driller on Site? Cz
a ❑ Is the well capped and Vented?
B� [I Is there evidence of a surface seal? L� S"
�Q ❑ Is there a 2"annular space on all sides of the casing? Zm
❑ -� Has the seal slumped? 14 ~ ' l .4 0
❑ 0— Is the well flowing or is there evidence of other leakage? 113 2s 3
❑ 13' Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
f,V ❑ Do the well site set-backs appear to be appropriate?
Comments
_pP"ass ❑Fail Inspector Date 611 sr&�
This loan may be scanned and available roc public view on the Mason County Web site. Reviaed:2!720I8
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