HomeMy WebLinkAboutWEC2023-00123 - WEC Application - 3/28/2024 �Zr v��� V J�iiIp15NBTM STREET,SHET-967 WA98584
MASON COUNTY IIII000111^III{❑I❑I❑I III SHELTON:380HELT N, EXT.400
COMMUNITY SERVICES OCT 0 9 2023 BELFAIR:360-2754467,EXT.400
ELMA:360-482-5259,EXT.400
o,uanays.�r as wamra.,..maam FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructlws
1. Complete Part 1.Incomplete applications vnll be rejected
WEC Receipt Number ya3. 2. Attach a plot plan and vicinity map.
l U�3 ❑ Cash 3. Submit this completed application with appropriate fee a minimum
tl- l ,gp Check of 24 hours in advance of inhating well construction. Refer to
0p`23 Mason County Environmental Health fee schedule for cost.
1 Da of Pa t 4. Meson County Public must receive notification at least 24 hours
a aoa3 prior to the drilling of the well.
PART 1:Applicant/Parcel hlentiflcatlon
Site Address // ?n `' /n. ji"in 14Akle field ¢ Stancam#
Drilling Finn elo a/.t„�-evDi•r/If,rnq Phone 5&d-836- 90 —
Applicant A /V vh J Phone ;Iw-
Mailing Address 11 1?t 6`IVIAS0 1 1R C
city � r��oe (,�/leW state zip 9 8 Sz/ly
Parcel Number o�oc �d y roZ OAO S O
Directions to Site /y1A50Aj Inxs RO 7D svAfAfya L.ePE L rllLTt R etJ C rALA OR C
aq MhSon[ 3CnISoN 'RL 75 A4.RSe LAKE 'RO
Is the well site within 100 feet of wit/seawater? ❑Yes ❑NIS'
If yes, a valiance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes 2Nb
NOTICE:All propose f comrecfions to crew wells are subject fo wataradequecy requirements at time oibulldirg pemlif per Mason County Title&M
Wafer u`a}, 'ldlor maY apWY fo aN nea'wells tlnlletl aRer January 19"',Zrlfe per ESSB 6081.
-- Applicant/Agent Signature
PART 2: Health Department Revlew(Staff Use Only) lTl
VES NO TAG IfCalled In
❑� i 24
-,/ Driller on Site? CAT- 4� a
❑ 10 Is the well capped and Vented? 6 ,
❑ Is there evidence of a surface seal? Lg7✓ -
IY ❑ Is there a 2"annular space on all sides of the casing? �� A
J❑' ❑ Has the seal slumped? fS .o y- {Z V3
❑ Is the well flowing or is there evidence of other leakage? - 1 It•5 S
❑ pr Is there evidence of cascading water? A
�� ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate? RI
Comments \'I �p W '1 16' YJ _..
❑Pass ❑ Fail Inspector. Date -., i b .
This form may be scanned and available for public view on the Mason County Web site. Rcviaed:?!7/2018
Mason County WA GIS Mason county Homcp- -�
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