HomeMy WebLinkAboutWEC2024-00040 - WEC Application - 3/4/2024 MASON COUNTY 418 N SHELTON:360-427-9670,EXT.400
0 COMMUNITY SERVICES SELFAIR:360.2754467,EXT.400
ELMA:360d82-6269,EXT.400
FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavmant Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
W EC Receipt Number 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
awA-M1 )l7 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Paymeml lq-L2 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification �y O E ELf N,rL.'N
d.Site Address f" �[qNs --AW C. Start Cana# ky _
Drilling Finn �AO�/ua By n—J�j lnw Phone ,36f -ei�,..310440
Applicant x" )-P Phone 'Jaz3
Mailing Address E' Asa- Ad G[J
city B P/ :1L 1111V State AIA zip q ?S.
Parcel Number ,1
Directions to Site irRr•S �^� 'ta S - 6sr
Is the well site within 100 feet of salt/seawater'? ❑Yes 8lqo—
If yes•a variance from DOE is required. Have you applied/received (circle one)a variance? []Yes RDT.
NOTICE:All proposed connecoons to new"Us am subject to wateradequacy requirements at Hire of Wilding permd per Mason County Title 6.68.
Waterusage reldnabonedg addlbonal roes may applyfo allnew,wells drilled agar January 19ui 2018 per ESSS 6091.
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Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG If Called In 29I2'K Eta 1''f
❑ Driller on Site?
❑ & Is the well capped and Vented? I-AT 1 K?' 24 0 4 4 L
❑ ❑ Is there evidence of a surface seal? N. o� Lotz-' _ I`L1 , 174 S23 Z
❑ ❑ Is there a 2"annular space on all sides of the casing? 1 e,r is r^
❑ ❑ Has the seal slumped? tS , O ' tr
❑ ❑ Is the well Flowing or is there evidence of other leakage? 0,0
❑ ❑ Is there evidence of cascading water? ro
❑ ❑ Is there evidence that the seal is at least 18 feet long? t� • - � 6 sU
JJC2-' ❑ Do the well site set-backs appear to be appropriate?
Comments IDp IS sA .. r..v- r
(Pass ❑ Fait Inspector Date . 'r L Iy
This form may be scanned and available for public view on the Mason County Web site. Revised:2J72018
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