HomeMy WebLinkAboutWEC2013-00113 - WEC Application - 9/26/2023 415 N BTM STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:3W 427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467.WE 400
ELMA:360482-5269,EXr.400
9)
FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Parmlt Number PavmeM lnMrmatlrsrl Instruction
1. Complete Part 1.Incomplete applications vn11 be m)ecied
W EC Receipt Number a� __ 2. Attach a plot plan and vicinity map.
3 - Cash 3. Submit this completed applicabon with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
coMason County Environmental Health fee schedule for cost.
l L t3 Date of Payment OL 4. Mason County Public must receive notification at least 24 hours
pnc r to the drilling of the well.
PART 1:Applicant I Parpi ldentMeaMm
Site Address /lzaa F S-fal 3.7 $tlGlr,va7 Start Card#In/GSN3bZ
Drilling Firm I' Phone
Applicant b I G _ Phone S'
Mailing Address
City GL L n.16er SUM Ir✓A zip 9 r335-aiii
Parcel Number 11I1LZZI - y7 - 940
Directionsto Site f1e a AI A CIDE n;;L=e)
rl, `;Ivmflu aa, r-
Is the well site within 100feetofsalt/seawate �'If yes,a variance from DOE is required. Have a variance? [-]Yes ❑No
NOTICE:Allproposedmnnediomtocrewwallsaresubjecttowateradeguacyrequiramenlswameorbuildirppe per Maam Countyrm$B6a
Wafer uaWee mablcbane and addNonal lees may apply to ail new walla dnlled after January fa",W18 per ESSB War.
v a—�Ca
L �77
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In Felt I- 10. 2'l
❑ 0- Driller on Sae? "T ; 9O.-3Tt, IitQ
❑ ❑ Is the well capped and Vented? 4f•b- tomb-:
Cl ❑ Is there evidence of a surface seal? tj-o.
ja' ❑ Is there a 2"annular space on all sides of the casing? uIIII��
❑ ❑ Has the seal slumped? A.D. 0
❑ 2r- Is the well flowing or is there evidence of other leakage? SFP 2 5 2023
❑ Z� Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? 'J•0.
'J21' ❑ Do the well site set-backs appear to be appropriate?
Comments pn kc:kl, .r
Pass ❑ Fall Inspector D• A. Data 1 • Z2- vt
This form may be scanned and available for pudic view on the Mason County Web site. Revised:2/7'2018
i �
, �
1 i
i /+ � ; , I
I
� : � ,
f � _
'� i ;
;.
�� i
�� � � i I I og5pp5 �
� ' � ¢ I ° �Y
�: ¢ / \ � ��
I ' � I
� __ i_._
_t ..,
li
�... / Iy :'��.
� ' g ! � b
� � I � - � �I � -z
' ,: �: '�
__.... _
�� —� � f
_.i '� _____ i �.
�' �� � g
,� �, I
`�� -__--
`.�..�� - � 'X�
� � _
-- --- -- .
}
� ,.
' z
' ,---- _ '
_� __
�,.,�....�... .._....._. . , �._.__�� Z
�"� i ._ ' I I --
`g_.,__.r..J...
, .
r
.,, __
,-
a . may s _ ...�
_ _ � .
� �
R s _�� a $