HomeMy WebLinkAboutWEC2024-00055 - WEC Application - 3/29/2024 10
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415 N 6"STREET,SHELTON,WA g6584
SHELTON:360-427-9670,FXTEXT�400
MASON COUNTY BELFAIR'.360482- 467' E)J.400
ELMA:360-482-5265,FXT•400
COMMUNITY SERVICES FAx:360>27-T7e7
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NOTICE OF INTENT TO CONSTRUCT A WELL
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P ml Mt M l�*^ ^'L 1. Complete part 1.Inocmplate applications will be rejected
Pertn� �r gL-J6 74 2, Attach a plot plan and vicinity map
Receipt Number¢ydr'1-J7 3. Submit this completed application with appropriate feeaminimum
W EC p Cash of 24 hours in advance of initiating well construction.
Refer to
Check Mason County Envir mmenlal Health fee schedule or ost
4. Mason County Public must receive notification at least 24 hours
Date of Payment, prior to the drilling of Me well.
PART 1'. Applicant I Parcel Iderdlfic"On Start Card# iJ
Site Address Phone i • �-
��
Drilling Firm phone _—
Applicant 9�y�
Mailing Address
States
Ctty,
Parcel Number
Directions to Site YeS ONO
Have you applied I received(circle one)a variance? Title 6,68.
Is the well site within 11H1 feet Of salt I seawater? OYes MNo Mason County
If yes,a variance from DOE is required. ,EBSB permit uirenrontsrutime8 Per ring Pe .
NOTICE:All proposed connePer
ctions to new wells W sobfo all new wells dolled after January
19"',2018 pe
Water rasVi<h'ons a additional lees may appb'
Applicant I Agent Signature
PART 2:Health DOPa ant Review(SfatF Uae Only) Called In G/GIB
YES NO TAG# 6l (3 I2`k
r--I, 0 Driller on Site?
0' Is the well capped and Vented?
�. 0 Is there evidence M a surface seal? 14-r Al T
�i Is there a 2" annular space on all sides Of the cesing? _ 111 T b b o 9
Has the seal slumped?
Is the well flouring or is there evidence of other leakage?
: Is there evidence of cascading water?
�. Is there evidence that the seal is at least IS
feet
e t long?
r-y Do the well site set-backs appear
14
Comments
,.rrplss ❑Fail Inspector - Correll Web ale. Revtsed:2172018
This form may be sunned and available for public Wew on tlN Meaee
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