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HomeMy WebLinkAboutWEC2024-00056 - WEC Application - 4/2/2024 415 N 6'STREET,SHELTON,WA 98584 MASON COUNTY SHELTON:360427-9670.EXT.400 COMMUNITY SERVICES BELFAIR:360-2754467,EXT.400 ELMA:360482-5269.EXT.400 FAX:360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment IrdormHian Instructions 'yyy��� 1. Complete Part 1. Incomplete applications will be rejected W EC Receipt Number g - s S1 2. Attach a plot plan and vicinity map, • IYV� ❑ Cash 3. Submit this completed application with appropriate fee a minimum &�N � Check of 24 hours in advance of miliating well construction. Refer to Mason County Environmental Health fee schedule for cost. Data of Peymen 7r 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1:Applicant I Parcel Identification Site Address 931 W Golden Pheasant Rd, Shelton Start Card# WE55951 Drilling Firm Advanced Drilling LLC Phone 360 273-7735 Applicant Dustin Hensley Phone 360 470-4195 Mailing Address 117 W Benthein Rd city Elma State WA Zip 98541 Parcel Number 31906-11.00020 Directions to Site US-101 S toward Olympia, Right onto WA 3 tamp, Right onto W Golden Pheasant Is the well site within 100 feet of salt/seawater? ❑Yes ONc If yes, a variance from DOE is required.Have you applied/received(circle one)a variance? ❑Yes ONO NOTICE Mprrpwed cmvrecf s to new wells are subject b wehr adequacy requiements ai lure ofbuilding pwmtpw Mason County Tde 6.W.. Wateruaegeresbceonsandaddi lhasmay WpybirerrsrvwellsdnN aaer January19",201aper ESSBM91, Applicant/Agent Signature PART 2: Health Department Review(Staff Use Only) a / ` YES NO TAG If o� P7 �I`"I D Called In %t %q ft fup tf�gqV (LAX-15 1A'U E] ❑ Driller on Site? I[� b� "' J 1�a❑ Is the well capped and Vented? LAX y to d4 7t�o6 ❑ Is there evidence of a surface seal? Wrb(': ) 7- El- 3 ❑ Is there a 2°annular space on all sides of the casing? CA ❑ Er Has the seal slumped? m ❑ .[3- Is the well flowing or is there evidence of other leakage? r— ❑ 0" Is there evidence of cascading water? ❑ ❑ Is there evidence that the seal is at least 18 feet long? p1 GT l°j ❑ Do the well site set-backs appear to be appropriate? rco✓mments Nr.AA Pib A tp Pass ❑ Fall Inspector Date q Zy Thm form may be sunned and available for public view on the Mason County Wab slm. Revised:217/2018 q | / , ) ! @ § � m � . � ! • i LU m � \ \ � | : 5 / ' ■ ! q