HomeMy WebLinkAboutWEC2023-00138 - WEC Application - 11/15/2023 4f 44 4W
415 N 6TM STREET,SHELTON,WA 98584
MA'+ON COUNTY SHELTON:360-427-9670, EXT.400
CCCIMUNTTY SERVICES BELFAIR: 360-275�467,EXT.400
ELMA:360-4J2-:269, EXT.400
a,1a'ma ri.,,,mse�wa,„x.d xrMcoony x..s, FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions 11
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number Z..S 2. Attach a plot plan and vicinity map.
0 1 ❑ Cash 3. Submit this completed application with appropriate fee a minimum j
❑ Check of 24 hours in advance of initialing well construction Refer to
00 r Mason County Environmental Health fee schedule for cost.
Y Date of Payment r LLqL% 4. Mason County Public must receive notification at least 24 hm
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
- y, / t �d Card# WL� "✓
She Address W Q C
.J
cc�
Drilling Firm ,fLJc���� (1 ' rl - PInonr�2jp t�� 7
Applicant 1=yrL It l!\5 1IN, #h0(�JC�1Y'-I Phone���2-0�
Mailing Address 3U4o
city ` ^ state kj.J A— zip 0.1C2:2 2 F(
Parcel Num14�ber 2 1 '— CJ^�f^J^O' -
Directions to Si e tt t \ V.IC. �
yc ,r� �v °
Is the well site within 100 feet of salt I seawat, o
If yes, a variance from DOE is required. Have you ap lied recewed (circle one)a variance? []Yes �N0
N077CE.All proPeeNd connections! w wells are su4f.f M waferadequacy requirements et flare of building parmd per Mason Counly Title 6.68.
Water usege stric6ore and additlo1 I is ray apply to all new wells drilled after January 19",2018 per ESSB 6091,
Applicant I Agent ignature
PART 2: Health Department Review(Staff Use Only)
YES Ng TAG# An Called In '11-& 2-H Fo ,f lb L'F
❑ /M Driller on Site?
We ❑ ❑ Is the well capped and Vented?
IV�p ❑ ❑ Is there evidence of a surface seal?
IWO ❑ ❑ Is there a 2'annular space on all sides of the casing?
y71 ❑ ❑ Has the seal slumped?
❑ V Is the well flowing or is there evidence of other leakage?
ElIs there evidence of cascading water? m
p ❑ ❑ Is there evidence that the seal is at least 18 feel long?
)(J ❑ Do r well site set-backs appear to be�appprropriate?
Comments S 1(�t/ I
Pass ❑ Fail Ins actor Data
This form may be scanned and avall able for public view on the Mason County Web site. Revised:2M2018
10 . �
Notice of Intent to Construct a Notica Number
Water Well WF54915
ECOLO
E°OILOGY`Y This form and required fees MUST BE RECEIVED by the Department
of Ecology 72 HOURS BEFORE you construct a well.
1. Property Owner _
Name
Deets Kdune
Mailing Address City State Zip Code
340 NE Davis Farm Rd Belfair WA 98528
2..Consulting Firm(it applicable)
Business Name
Mailing Address City State Zip Code
Email Address Phone Number
3..Well.Site Location
County Name Tax Parcel Number
Mason 22125305001
Street Address City State Zip Code
Lot 5 E Olympic View Street Belfair I WA 98528
Township Range /.Section %(within 160 acres) '/.-' (within 40 acres)
22N 2W 12 SE _ SW
Latitude Degrees Longitude Degrees
47.40426 -122.87180
4. Project Details
Estimated Start Date Project Name No of Homes
11/13/2023 Olympic View #1 E
Well use: Group Domestic Work Type: New Water Right Permit: Not Required
5. Driller Details.'
Professional Name [Architect I License Number
Engineer I Surveyor](if applicable)
Drilling Company Name Phone Number
DAVIS DRILLING INC (360) 275-5367
Licensed Driller Name Driller License Number
MICHAEL DAVIS 0797
Comments
6. Fee Summary -
Total amount due for wells with casing diameter less than 12": $200.00
Remit payment to: Department of Ecology Cashiering Unit, P.O. Box 47611,Olympia WA 96504-7611
OR Pay online at https://appswr.ecology.wa.Roy/weliconstruction/Wells/Notice0fintentPaymentReguest.aspx
Notice Status Date Confirmation I Cash Jour:tal Number
Pending 11/10/2023 10:58:57 AM 23111014353352