HomeMy WebLinkAboutwec2023-00092 - WEC Application - 3/13/2024 ID MOIL s v 19 I�I 415 N 0STREET,SHELTON,WA 98584
MASON COUNTY (Isn�} CII�JI SHELTON:360427-9670,EXT.400
COMMUNITY SERVICES AUG 07 2023 BELFAIR:360-2754467,EXT.400
ELMA:360482-5269,EXT.400
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment In/omnatlon Instructions
t. Complete Part 1. Incomplete applications will be rejected
WEC Receipt NumbeQ .� 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating wail construction. Refer to
Mason County Environmental Health fee schedule for cost.
GW C7 r% Date of Payer,eQ�J�[�3 4. Mason County Public must receive notification at least 24 hours
�I>( -_rr' ii prior to the drilling of the well.
PART 1: Applicant I Parcel Identification 6/40 E``t W LAI ,,c �7
Site Address I7`Lr✓'S�•ire SS�Fa..4 tide Start Card# A-'94-!7:7 7
Drilling Firtn CQ70 W<-fPI� /'a/�.' HG� Phone IRAfo'c J0-9—d U
Applicant S6h7-lay y C Phone
Mailing Address ?,�J�/// E /c/f$O/� Aed Ly
City Ael F-C-/R �G1� State zip
Parcel Number
Directions to Site S •tie .rS��t-..�
Is the well site within 100 feet of salt/seawater? ❑Yes D90
If yes,a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes E3IVff—
NOTICE:AN proposed oorw a ors to new wells are subject to water adequacy requirements at time ofbuildirg permit per Mason County TNe 6,68,
wets.usage rsajo,ona aym (fees mayapp/y so all new wells dolled after January W,,2018 per ESSS 6091.
e
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) 'I
YES NO TAG It Called In
❑ .' Driller on Site?
❑ ,a' Is the well capped and Vented? ,LAY- 4-1 . 21 tT I`{
�- ❑ Is there evidence of a surface seal? LotSb : -1 Y2. % 7 `I`i4
.� ❑ Is there a 2"annular space on all sides of the casing?
❑ J21 Has the seal slumped?
❑ _,Er Is the well flowing or is there evidence of other leakage?
❑ 47r Is there evidence of cascading water?
Cl _ ❑ Is there evidence that the seal is at least 18 feet long? nSoT o6SErL./6D
.jT/ ❑ Do the well site set-backs appear to be appropriate?
Comments 1 or.(Sr TE -1" t
Airs-
p4ass ❑ Fail inspector Date 3113 L
This form may be scanned and available for public view on the Mason County Web site.. RCvised:217/2018