HomeMy WebLinkAboutWEC2024-00045 - WEC Application - 3/15/2024 r , .
415 N 6TM STREET.SHELTON,WA 98584
TY MASON COUN SHELTON:360427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467,F_7(T.400
eaayrmm:ye wx.amco .mnxwa ELM&3604a2-5269,E)CT.400
FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
N 1. Complete Part 1.Incomplete applications will be rejected
W EC Receipt Number(If-�49 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
. Check of24 hours inadvanceof initiatingwell construction. Referto
Mason County Environmental Health fee schedule for cost.
Date of Payment - 4. Mason County Public must receive notification at least 24 hours
�L J prior W the drilling of the well.
PART t:Applicant I Parcel Identification
Site Address g<,-O/J .v)im /�,'S'S- �� C/'edoyd Start card -b 9U# lyle-5
Drilling Finn � 7Er PhoneiRLV--9 -C/0011
Applicant /ris/��,/ ,i_7ao v� Phone A0- J-J89y
Mailing Address
city F_o1Aei. +a//m State Gr/A Zip Z4t3712
Parcel Number �107�(96731?
Directions to Site
. Is the well site within 100 feet of salt/seawater? ❑Yes
If yes,a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ❑q-. —
NOTICE:All pmposed connecbdns to new wells are subject fo wateradequacyrequirannrnis of time ofbmlding pemul per Mason County Title fib&
Waterusagerasfncdo, fiarrel may apply ballrem wells drilled after January 19m,2018per ESSB 6091,
Applicant I Agent Signature
PART 2:Health Department Review(Staff
l�/Use
QOnly)
-7 �/
YES NO TAG# U (y III V ( � Called In 'yu°/Zy '7''A
❑- Driller on Site?
p���jj ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
V10 ��99G8
❑ ❑ Is there a 2"annular space on all sides of the casing? z 7
❑ Has the seal slumped?
❑ is the well flowing or is mere evidence of other leakage?
❑ Is there evidence of cascading water? m
i P//] Is there evidence that the seal is at least 18 feet long?
N v ❑ Do the well site set-backs appear to be appropriate? A
Comments y;1.
Pass ❑Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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