HomeMy WebLinkAboutWEC2024-00069 - WEC Application - 5/24/2024 TAti vFF
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MASON COUNTY SHELTON'360-427-9670,EXT.400
COMMUNITY SERVICES MAY [ 4 '24 fJ BELFAIR.380-275d467•E)Cr.400
ELMA:360-482-5269,EXT.400
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavm nt In/ormatlon Instructlom
����qq�����[[��yyy�� 1. Complete Part 1.Incomplete applications will be rejected
W EC Receipt Number2ax- X 2. Attach a plot plan and vicinity map.
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Cash 3. Submit this completed application with appropriate fee a minimum
"\ Check of 24 home In advance of iniUafing well wnswcbon. Refer to
Mason County Environmental Health fee schedule for cost.
Data of Payment 4. arras on County drilling public
the wellelve notification at least 24 hs owl
to the
PART 1:Applicant I Parcal Identification
Site Address l0jo NE-�r Start Card# WE �Ln 7
Drilling Film � v�5 �Jil lY'�1 Phone
Film �10'7.7S Srl(07
Applicant �7 0:)11�1 e, f y r 1 Y'� �I ' ,1 c Phone
Mailing Address
City l \ C Ma, State 1NA zip h(_O
Parcel Number 22. fnv 11 `- 1, ^ ^ 1 On �,
Directions to Site FY�YY1 f v S/\a�� A M--1 Y'[ l l A 'Q 1 r�.A�P./I S
Is the well site within 100 feet of sell/seawater? ❑Yes []NO
If yes,a variance from DOE is required.Have you applied/received(circle one)a variance? ❑Yes ONO
Wahrusa9^^ ^elerd^e ifiMdlees may apply ^�'wall.debd aner January l9',018p E 55 B�1�Mason County Title a.68.
V
ApplicaWl Agent Signature
PART 2:Health Department Review(Staff Use Only) a ll i'1- r.loa7 N
tr I7- IL't Fell
YES NO TAG# Called In
❑ ❑ Driller on Site? C—P, L+-r-
❑ ❑ Is the well capped and Vented? 1,4 Gr
❑ ❑ Is there evidence of a surface seal?
❑ ❑ 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?
❑ ❑ Is Mere evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments 1/0 well II /16/m? y
❑ Pass ❑ Fail Inspector _ _ Date
Thy farm may be"anew and available for public view on the Mason County Web site. Reviwd:2/7/2018