HomeMy WebLinkAboutWEC2024-00111 - WEC Application - 9/24/2024 Cs�'AfEJ lFt�
15 N B. STREET,SHELTON,WA 98W4
MASON COUNTY SEP 2 7 2024 3ELTON:350-427-9870,EXT.400
COMMUNITY SERVICES BELFMA:360482-5289,EXT.400
ELMA:380-482-5289, EXT.400
A46prImMFiwemees+lasuvice.,wewea BY_ FAX: 360-427-77e7
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavmerrt Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 0 YI7I 2. Attach a plot plan and vicinity map.
2024 -00111 0 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
'/ Meson County Environmental Health fee schedule for cost.
Date of Payment dq'�'Z7 4. Meson County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant/ Parcel Identification
Site Address 312 E Orchard Beach Drive Grapeview Start Card# 57907
Drilling Firm Grande Drilling Phone 206.510.6539
Applicant Orchard Reach Cnmmuri ty Group Phone 360250.9110
Mailing Address 41 E Orchard Beach Drive
City Grapeview Slate WA Zip 98546
Parcel Number 22127-50-01901
Directions to Site Hwy 3, right on Island View Rd, right on Orchard Beach Rd, then left on Orchard Beach Or
Is the well site within 100 feet of salt I seawater? ❑Yes ®No
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ❑No
NOTICE All proposed connections to now wells are subject to water adequacy requirements at time of buiding permit per Mason County Tile
6.68,Water usage resaiclions arM additional fees may apply to all new wells drilled after January 19e,2018 per E666 809/.
2 ., Vice President OBCG
Applicant I Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Celled In `7"(Z-F I -4 fa-R LULL
I L
E] Z' Driller on Site? -r
❑ 4a Is the well capped and Vented?
E ❑ Is there evidence of a surface seal? L
MT =
EJ ❑ Is there a 2" annular space on all sides of the casing?
❑ 0- Has the seal slumped? L'p r•(({ ' 65 Z9
❑ .[D' Is the well flowing or is there evidence of other leakage?
❑ ,0" Is there evidence of cascading water?
❑ Is there evidence that the seal is at least 18 feet long?
�]- ❑ Do the well site set-backs appear to be appropriate?
Comments it 13AC-5 RQSEN-T— tib WLtIQrX -CafVV obvwa pt�{
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[J-Pass ❑Fail Inspector Date to/`ZZ�y
Thisform maybe scanned and available for public view on the Masan County Web site. Revised:2/7/2018
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