HomeMy WebLinkAboutWEC2024-00096 - WEC Application - 8/8/2024 MASON COUNTY 415 N SHELTON:360 427-9670,EXT.400
0 COMMUNITY SERVICES BELFAIR:360-275407, MCI.400
ELMA:360d825269,EXT.400
e.aag vw. „ec.ew,w.ixdmc«,.,.,,,�yxda, FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Parmlt Number Payment Information Instructions
Complete Pan 1.Incomplete applications will be rejected
WEC Receipt Number=Q- b Attach a plot plan and vicinity map.
/trJ1�f_nnh(j ❑ Cash 3. Submit this completed application with appropriate fee a minimum
oN.ld."—C-�AA,rI bn Check of 24 hours in advance of initialing well construction. Refer to
>1 Q Mason County Environmental Health fee schedule for cost.
Date of Payment V 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 /Ve/a/I/ -Y"' IJfGC�IsHr,'/�1 A Start Card#
Drilling Finn e� &l&I OL' .' Phone
Applicant //-'ri {+6t^Q /rrES Phone -7/!0
Mailing Address 7 e�-/ �✓y '"
CRY 'R/-;l l !., f r j t� q� State yGr 51 ,(Z pp /Z
Parcel Number 6
Directions to Site ,,���
Is the welt site within 100 feet of salt/seawater? ❑ [E Yes NO
If yes, a variance from DOE is required. Have you applied/received(circle one)a varianO EKY EJNJ'-"
NOTICE:All proposed cmrnectlons fo new wells are subject to wateradaquacy requirements at bme of bueding permit per Mason County Title 6 68.
Walerus restdcaonsand additio may apply re all new wells drilled after January 19',2018 per ESSB 6091,
plicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
❑ 0- Driller on Site?
❑ ®- Is the well capped and Vented?
®' ❑ Is there evidence of a surface seal?
❑ Is them a 2'annular space on all sides of the casing?
❑ ❑ Has the seal slumped? Is- sale c"ve
❑ Er Is the well flowing or is there evidence of other leakage?
❑ iK Is there evidence of cascading water? a•C�am
❑ ❑ Is there evidence that the seal is at least 18 feet long?.'
LT ❑ Do the well site set-backs appear to be appropriate?
Comments
❑ Pass ❑ Fail Inspector 1flI'RU5 S7J6nI_L_CV Date ! I/b Ir
This form may be scanned and available for public We.on the Mason County Web site. Revised2/7/2018
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