HomeMy WebLinkAboutWEC2024-00064 - WEC Application - 4/30/2024 �AHIuyA Rtvt2 Rt�
415 N BTa STREET,SHELTON.WA 98584
MASON COUNTY SHELTON:360-275 870.EXT.400
SELTON::360-2764467,EXT.400
COMMUNITY SERVICES ELMA 360A82-5269.EXT.400
Buds W'nFAEmYannel/NSMACommnItY1MYN
FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Instructions
Permit N row P vment Infamatlon e e 1 Complete pad 1.Inwmplat.applications will be ralecled
Receipt Number3014"AI-{�p 2• Attach a plot plan and vicinity map.
WEC 3. Submit this completed application with appropnale fee a minimum
�y�av�rr� I� p ❑ Cash of 24 hours In advance of initiating well wnstmction. Refer m
a/d14.�1'�d�1 rp Check Meson County Environmental Health fee schedule for cast.
Date of Payment--4'�i SA 4. ^�ooto aerie drilling of the well�ive notification at least 24 hours
pri
PART 7:Applicant 1 Parcel IdeMNleetion n,JCS f St rt Cats#
Site Address 01U Nf V F+ rro
Phone 0 ,y31s
DrillingFirm n/tS t/Y1� u t,,�� � 07
!� r _ ..n 1N Phone 7A�d ���
Applicant
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Mailing Address Z070I � men
City �AL tt A _ Stale �._ Zip
Parcel Number 7 ) " 4 00
���(oS NE��Nafti K4'vtr �I'v�L✓ti( �h acres
Directions to Site 'yO
Is the well site within 100 feat f seit/seawatefl ❑Yes No
If yes,a variance from DOE is required.Have you applied I received(circle one)a variance? 0Yes No
NOTICE:Ae proposed counecears to new walls are subbed fo water ada4uacy moulremenis of term ofbuddmg Pants par Mason County Tills 6.68
Wahrueege restddlons and additional has may apdY fo eN new wells dnlbtl soar January 19",2018pw ESSB 6091.
Applicant/AgenE Signatura
PART 2: Health Department Review(Staff Use Only)
Called In
YES NO TAG#
1 Driller on Site?
ZI Is the well capped and Vented? ,-y% 41
Is there evidence a surface seal? " -'tJ�•�
Is there a 2"annular space on all sides of the casing? I
LZJ, Has the seal slumped? 1 A tf
EJ Is the well flowing or is there evidence of other leakage? 7
❑ Is there evidence of cascading water?
Is there evidence that the seal is at least 18 feet long?
PIVI' ❑ Do the well site set-backs appear to be appropriate?
��Comments Date
U(1 Pass ❑Fail Inspector
/" This form may be scanned and available for public view on the Hawn County Web site. Rcviwd2/7/2018
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