HomeMy WebLinkAboutWEC2024-00076 - WEC Application - 6/7/2024 G�n'PE�Ia.�(�wynl
415 N BTM STREET,SHELTON,WA 98584
MASON COUNTY SHELTON-3804T/-9670,EXT.400
0 COMMUNITY SERVICES BELFAIR 360-275-4467.EXT.400
saa ove�.sr-..w.rx,as. � ELMA 3604182-5289,EXT.400
FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
�.� 1. Complete Pan 1.Incomplete applications Will be rejected
W EC Receipt Number C r ; 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
GSdL heck 1_I' of 24 houm in advance of inhiating well wnstmcbon. Refer to
WV U I� Mason County Environmental Health fee schedule for cost.
Date of Payment 1 4. Meson County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Parcel Ideentificatio/n� /
Site Address 213 � / Vt (S O V Stan Card# W E r(07Zj
Drilling Firm 1 Z)rr1I�(t ✓LA Phone J360- ZZES�r-7
r—
Applicant SAyaxk r& I$ f Phone 71�
Mailing Address TM..y0 0
city rdl r I rl 'I nnr� State Zip _
Parcel Number )2227— 6 —000W' r� _
Directions to Site 'Tot kce A/LS� � I,,.fl(l GiLKpur" leor ✓k01r 'en
Is the well site within 100 feet of salt/seawater? []Yes pyNo -
If yes,a variance from DOE is required. Have you applied 77 received(circle one)a variance? Yes ❑No
e
NOTICE:Aepmposad connections to new wells are subject to waferadepuacy maulremenfs at fime olbuildirgMUN
pemvt per Mason County Tifla E 88.
Water usage mabi ' ns end sdM'nnel faas may apply M all new wells dnllad after January 19112018 per ES1MR71_
Applicant I Agent Signature 0 7 2024 IyIIIUIIU^IIIIIII
PART 2: Health Department Review(Staff
L Use Only) B
YES N..O, TAG# ♦�v+ Called In
❑ `y,g/ Driller,,Site?
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?
❑ ����Has the seal slumped? ¢7. 36031 T Id OFFVa
Elwe Is the ll Bowing or is there evidence of other leakage? 511 711
❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?pI.O
i ❑ Do the Well site set-backs appear to be appropriate? s
Comments I Tz ij yc ,' a s o,`}
ass ❑Fail Inspector _ Date 4(2.0 (14
This form may be scanned and available for public view on the Hawn County Web site. Revixd2r72018
Mason County WAGIS Web Map
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