HomeMy WebLinkAboutWEC2023-00105 - WEC Application - 9/11/2023 � LII�I�
41 BT"STREET,SHELTON,WA 96584
COMMUNI�TYSERVICES SEP 1MASON CUNTY1 2023 BHELTDN:380427-9670,EXT.400
BELFAIR:360-275 4467,EXT.400
a,+msri,..mae.,,,onn,.M �,(n ----- ELMA:360 FA2XX:360-427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit-Number eat Instructions 1. Complete Part I1.mple None IN be rejected
a� Recsrot Num.—n rJ'T 1D 2. Attach a plot plan and viciniy map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
I, �n Check of 24 hours in advance of imitating well construction. Refer to
OV1 V-J Mason County Environmental HeaNh fee sdrodule for cost.
l Dale of Paymem 11 3 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Pamel Identification
Site Address 400 f.11F r)C_W0-ff6 Hill<- Qn Staricam#/WL'-'SWO 91
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Phonel'�(. 97 53l
Drilling Firm ,_q �
Applicant lYln-ffhcka,+�� e m Phone
Mailing Address +{ I.
City ^7 State WfI zip
p Q 4 tf3
Parcel Number 17 Z1 ? — 7,5 — delta ] �^
Directions to Site 10kii llrf4la� Hil1C' n GIM Taf{rs1/a Rlaelc9:0 lsk On Rlyh
Is the well site within 100 feel of salt/seawater? ❑Yes j*o / v/
If yes,a variance from DOE is required.Have you applied/received(circle one)a variance? []Yes E!INo
NOTICE:Allproposed comrec m to new wells are subject to waferedequwyrequirertrents et time abu8din9 Pennitpar Mason C.-O Tilta 6.68.
Wafer use areNdctlruaM adsona,7 may appy to all new walla tldlled after Jenuery 19",2018 per ESSB W91.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 7I>A/2y rout � I 3®'Z`{
�] ❑ Driller on Site?
w<o ❑ ❑ Is the well rapped and Vented? OV7 L04( '0�7(t f 7G0
wo ❑ ❑ Is there evidence of a surface seal? T (/{f !'•,"
16 ❑ Is there a 2'annular space on all sides of the casing? of IYY,n
p(o ❑ ❑ Has the seal slumped? l J Z
❑ Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water?
W ❑ ❑ Is there evidence that the seal is at least 18 feet long? `OVI —1 Z
Ill' ❑ Do the well site set-backs appear to be appropriate?
Comments
PPass ❑ Fail Inspector _ Date
This form may be scanned and available for public view on the Mason County Web she. Revised:2/7/2018
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3083 E AtASON8F15ON 0.D. CRnI'El7EW,WA 98596 DESIGNER: ROBFAT H.PATSSE
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