HomeMy WebLinkAboutWEC2024-00048 - WEC Application - 3/18/2024 lul=1"7�II II15 N 6TM STREET,SHELTON,WA 985"
MASON COUNTY (I(}(,} IIGII SHELTON:380d27-9670,FXr.400
COMMUNM SERVICES )1 ,R ) 3 t.L BELFAIR:360-2754467,FXr.400
aaaxri.,,:ae.n .m a.haca....�yx.+a ELMA:360482-5269,EXT.400
BY.- ---- FAX:366427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
'to Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 2� 4. Mason County Pudic must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Appitcartt I Parcel Identification
Site Address 910- E_/1 kit' I,AJ lik k< jillnD k Start card#
Drilling Firm Phone 360-406 -gdgf-
Applicard (nn/4 Vd 0 &J-1Isl Phone ?66—.22J-QP1
Mailing Address R0;7T- L• Oce 1�-$4 a
city �l�n State ✓A zip q b'S 8
zl
Parcel Number
Directions to Site
Is the well site within 100 feet of salt/seawater? Dyes KNo
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? ❑Yes ETNo
NOTICE,All connecllans W new wells am subject to wateratleauacy moukaments at Urns e/buildirg pemltper Meson County Tile 6.68.
WaterusVe slrklons arM atldrtional fees may apply b all new wells drilled allar January 191^,2018per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
❑ g Driller on Site? LAT _ I 2J &It -7
❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
❑ Is there a 2'annular space on all sides of the casing? J `y
Has the seal slumped?
❑ Is the well Flowing or is there evidence of other leakage
El
❑ Is there evidence of cascading waler? �/�f'�_
Is there evidence that the seal is at least 18 feet long?
4 ❑ Do the well site set-backs appear to be appropriate?
Comments
hipass ❑ Fail Inspector Date 7J
r- This form maybe sunned and available for public view an the Mason County Web site. Revised'inI2018
PHILLIPS LAKE DIV. 2 TR 80
E pN1l-UPS
APPR®V
OCT 2 4 2023
MASON COUNTY ENVIRONMEN1
i' \ DJA
\ � / MN
%
\ � l
i
\\ oe
Um N
i
THi:0-24"Gravelly Loamy Sands \ TH2: 0.21"Gravellly Lowry Sands
Broom Brown
Heavy f
Roots
24-W Madum Sands with Gravel 21-52" M Jarc Sands
Rods Some Loam
54"Bohan Oftest pit
Roots
52'Botorn of Test pit 215
Same Compaction
TM:0-24°Very Gravelly Loar y Sands
Rods
24 W EArernely Gravelly Sands
Meclum Sands
Loose well Drained soil
Some Roots
00"Bottom of Test Pit
No Resoi tie ford t?r
Sryr.t+Bo
.W 9bfeeer�h ewms aE bdpn ae msea m asaT�a'b
ausaahvn Memn GuAYP��Ue1tR SietV!atl Ce Sepee0aa9aeiwbee beret hry�'
M1bMCo+�YYhlN paprErvlaaMmkabllfglbl6f81 tlrsgeccysmr.w atr ai]LIRYYM