HomeMy WebLinkAboutWEC2024-00104 - WEC Application - 9/3/2024 415 N 6TM STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360 427-9670.EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467,EXT.400
ELMA:3604825269,EXT.400
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavmem Irrtomnation Instructions
1. Complete Part 1.Incomplete applications will be rejected
W EC Receipt Number a1� 2. Attach a plot plan and vicinity map.
aCT:A;1 q ❑ Cash 3. Submit this completed application with appropnate fee a minimum
❑ Check of 24 hours in advance of Initiating well construction. Refer to
,,..J / Mason County Environmental Health fee schedule for cost.
Q C) ✓r Date of Payment a7 4. Mason County Public most receive notification at Isast 24 hours
prior to the drilling of the well.
PART 1:Applicant/Parcel Identification
Site Address 684 SE Arcadia Rd, Shelton Start Card# WE57266
Drilling Firm Advanced Drilling LLC Phone 360 790-7373
Applicant Bill Mctumal/Pedro Sebastion Phone 360 280-2236
Mailing Address PO Box 12048
city Olympia State WA zip 98508
Parcel Number 32029-14 90220
Directions to Site FonSEArQadjand. Riaht down side road to site
Is the well site within 100 feet of sa8/seawater? ❑Yes IRNO
If yes,a variance from DOE is required. Have you applied I received(circle one)a variance? []Yes [:]No
NOTICE.AN propmed"nec4ans to now wells are subject io wateradequacy mquifemenrs aroma orbuNdhp peat per Mason County 7Poe 6.68.
Weler usage restrictions errs addliional lees may apply malt new wags drilled attar January 19^,2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) �i
YES NO TAG# & FIV 066 Called In 9/6/2y ✓ q/gl Zy
❑ 0 Driller on Site?
❑ Is the well capped and Vented? 49
❑ s�(AO���
vo ❑ Is there evidence of a surface seal? (Y
❑ Is there a 2"annular space on all sides of the casing? �
\� 1p�y
❑ M Has the seal slumped? ( : 4�, '�'bp Li �\
�,r] Is the well flowing or is there evidence of other leakage?
❑ e :�zi.at7s
❑ ® Is there evidence of cascading water?
Y/p_ ❑ ❑ Is there evidence that the seal is at least 18 feet long? I Wj B PN a66
❑ Do the well site set-backs appear to be appropriate?
Comments
'Gl Pass ❑Fail Inspector _ Date 0
T This tom may be donned and available for public view on the Mason County Web site. Revl90d:2n2018
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