HomeMy WebLinkAboutWEC2023-00094 - WEC Application - 3/7/2024 AUG 0 ] 2023�II�Fy41J 6Ta STREET,SHELTON,WA9a564
MASON COUNTY SHELTON:360-427.9670,EXT.400
COMMUNITY SERVICES BY------------- BELFAIR:360-275i467,EXT.400
ELMA:380-462-5269,EXT.400
FAX:36OA27-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Cl1 Imatuetbna
4,I 1. Complete Part 1.Incomplete applications wig be rejectedW EC Receipt Number� / 2. Attach a plot Wan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
�/ Mason County Environmental Health fee schedule for coat.
L.1�� • Dale of Peymenl u • 4. Masan County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applksrtt I Pascal IdeMMcatlon G C
Site Address n Via F1 �$ Start card# w y
Drilling Finn v Phone
d
Applicant Phase
p t
Mailing Address f U 7(na->
city �� i Y State LVCI— zip
Parcel Number ( 300000 q�,
Directions to Site TT..f� ✓ Dr, U� ` F!&N$ 't
v ,y�
Is the welt site within 100 feet of salt/seawater? ❑Yea ICA'so
If yes, a varianca from DOE is required. Have you applied I received(circle one)a variance? ❑Yes ONO
Wlerr usagoprvaroi i oru enMilo leeasmey epd/t- 1 ID d'o muA uno o-,2oi8 r e,ESSB MailPer, Meson County l-rtb 6.88
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) I
YES NO TAG At -b?4� r2- 0 Called In rlln ll`1 ysll tI)�I2�
Driller on Site?
Is the well capped and Vented?
❑ 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? rdo j ciP W"�_0 �q
r Is there evidence that the seal is at least 18 feet long? t for
I�7 ❑ Do the well she set-backs appear to be appropriate? r
Comments w (. � A�� .1�r�,py/-4.
❑Pass ❑Fail Inspects fY'd4�9-(AA , "; Date
f.�oTC: ,Ikt 0A, HD 6A¢av7.1 r "a + *'*" P"b F[pW,.IG. [rose ENDS erb cto Jr.[D
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