HomeMy WebLinkAboutWEC2007-00231 - WEC Application - 9/21/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
'Always Working For a Safer,Healthier Mason County"
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA(360)482-5269 BELFAIR(360)275-4467
WEB htto:#/ co.mason.wa.us FAX(360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
PECEIVE^
SEP 2 12907 � //II Receipt Number: 541007- 9p3 WEC: 07 �3
1 Complete Part 1,incomplete applications will not be accepted
E N'd I. ,i . , r1L 2 Attach a plot plan and vicinity map
HEALFH . 3 Submit this completed application with appropriate fee(s)a minimum of 24 hours in
Date Received advance If initiating well construction
4 The Mason County Health Dept. Must receive notification at least 24 hours prior to the
drilling of the well
PART 1:Applicant I Parcel Identification
Site AddrdsGreenview Ln Shelton, WA Start Card#WE07486
Drilling Firm Arcadia Drilling, Inc Phone 360-426-3395
Applicant David Nail Phone 360-426-1366
Mailing Address 2501 E. McEwan Prairie Rd
City Shelton State WA Zip 98584
Parcel Number 32135250D013 321 3T z3 94013
From Shelton,travel north on Hwy 3 and then turn left on Mason Lake Rd. Then turn right on
Direction to SiteMikkelson rd, then right on Greenview Lane. Site is on right after 720 with Arcadia Drilling Sign.
Is the well site within 100 feet of salt/seawater?❑Yes ®No
If yes, a variance from DOE is required. Have you applied/received (check one)a variance?[-]Yes ®No
Connie Williams(for)Arcadia Drilling, Inc.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# ,r AA toZV Called In /D -L-
EI
tew On Site?
Is
Is the well capped and vented?
❑ Is there evidence of a surface seal?
IT ❑ Is there a 2"annular space on all sides of the casing?
❑ Has the seal Slumped?
❑ Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water?
r ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
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