HomeMy WebLinkAboutWEC2024-00103 - WEC Application - 9/3/2024 A&A-ram
6-STREET,SHELTON,WA985M
MASON COUNTY 415 N SHELTTON 360427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754487,EXT.400
s+r...a..,:ar•..mmn.+xdxnc«....nw+n EUAA 360482-5269, FXr.400
FAK 360-427-T787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
�� 1. Complete Part 1. Incomplete applications will be rejected
W EC Receipt NumberA `t' 2. Attach a plot plan and vicinity map.
�a(4 _ ❑ Cash 3. Submit this completed application with appropriate fee a minimum
Pe Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 3 q 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 0 E Crestview Drive Shelton Start Card# WE57267
Drilling Firm Advanced Drilling LLC Phone 360 790-7373
Applicant Bill McTumal Phone 360 280-2236
Mailing Address PO Box 12048
city Olympia state WA zip 98584
Parcel Number 32022-77-90011
Directions to site Hwy 3 to Agate Rd. Right on Crestview. 1500 ft past Agate Loop on Left. Follow to em
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 ONO
NOTICE Aff pmpased connecdans to new welts are subject b water adequxy requlrenrenfs ar time of budding permd per Mason Camry T1 .68.
Waterusage restrictions aW additional lees may apply fo all crew wells Billed after January Ism,2018per ESSB 6091.
PA W 444 yttitOft j ,~1 yEHi`
plicent/Agent nature ���
PART 2: Health Department Review(Staff Use Only) • ��� O�,_ j
YES NO TAG# k�\ (� a Called In Q'24/iy prf S/2%1�.zy Y ��
tJ ❑ Driller on Site? yN
LQT'
❑ Le' Is the well capped and Vented? �7. 2.t 2$.�4
0- ❑ Is there evidence a surface seal? �O r1G -2- c>
❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ,L3— 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?
K ❑ Do the well site set-backs appear to be appropriate?
�Comments t 2 6'-
�Wass El Fail Inspector Date
,/ q 2-T Z 1
This form may be sunned and available for public view on the Mason County Web see. RCviwd:2/7/2018
3 �0 � a - 7 � - 90011
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