HomeMy WebLinkAboutWEC2024-00029 - WEC Application - 2/20/2024 C }
415 N 6-STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,EKE 400
COMMUNITY SERVICES BELFAIR:360.2754467,FXT.400
aaannm�r � c e ELMA:360-482-6269,EXT.400
FAX,360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permh Number Pavmam Information Instruetiona
1. Complete Part 1.Incomplete applications will be rejected
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WEC Receipt Number�_UO O 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
l9- Check of 24 hours in advance of initiating well construction. Refer to
Meson County Environmental Health fee schedule for cost.
Date of Payment 2 �y 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART d: Applicant/ Parcel Identification
Site Address 51 C ffbme-<taad A ri✓t— (ra 4 Start card If LII� 5 5 543
Drilling Firm All( ✓a K[eed P-r,11:& LI Phone 3L0710-737�e3�•1 G
Applicant NkL 1 N W A-S A ��' �' Phone 3(OD Y9.3 -T /5J
Mailing Address PO Pjp r 491 2t:•.y+ti
city A'(,* l. state W/-- zip 9 $ Szy
Parcel Number
Directions to Site U I k 3 -� "--,,(� /D1
Is the well site within 100 feet of sell/seawater? ❑Yes j No
If yes, a variance from DOE is required. Have you applied/ ceived(circle one)a variance? []Yes ❑No
NOTICE:AB pmpased L011nemtlons M crew wells are subject Ir wate�adcquacy nvluinanenfs ar elms a/buildirg yerrrd per Mason County Tine 668.
Water usage ryes%aJp s and additional lees my apply Wall new wells dolled after January 19°i.2018 per ESSa 6091.
Apolicant/A ent Signalture 14
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PART 2: Health Department Review(Staff Use QnIyL YES NO TAG# tl ~ O Called In
❑ Driller on Site? a(7. 3 1 7 Z 2 "?
❑ _,E� Is the well capped and Vented? 4tiT'
❑ ❑ Is there evidence of a surface seal? • �' bpi&• ^ 12Z
,fa- ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the net slumped? N -0. r-
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❑ -PI Is the well flowing or is there evidence of other �her leakage?
❑ ❑ Is there evidence of cascading water? 'r O • Z
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
Comments jtj 1j - Rk C. balu,r A: r-y 2-1711
❑ Pass ❑ Fail Inspector Date z f<
This form may be sunned and available for public view on me Mason County Web site. Revispill/7/2018
Mason County WA GIS Web Map
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214/24,Gv'4 AM Gmail-Estimate 3976 from Advanced Drilling LLC
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