HomeMy WebLinkAboutWEC2023-00132 - WEC Application - 11/1/2023 415 N 6Tx STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467, EXT.400
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s a FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavment Infarme on Instructions
1. Complete Part 1. Incomplete applications will be rejected
^C Y Receipt Number 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 well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
Site Address mil 5t CHANLIL PCIIN-T AD Start card# VAt S4131
Drilling Firm MACRKIC �b 2NS Phone a(aD-�L4 -38D5
Applicant (%ptTke INE" Ppts EN Phone7(--315 -3
Mailing Address Sl SE CNANND. 'POINT Rb
CRY '5"F T0lvQ State KA Zip 925-y
Parcel Number 3 Z o 25 - Z.1 -0_0
Directions to Site C"'LNNtL- POINT RI) -F-o 54E
Is the well site within 100 feet of salt/seawater? ❑Yes)ZNO
If yes, a variance from DOE is required. Have you applied I received(circle one)a variance? ❑Yes ❑No
NOTICE:AN proposed connections to new wags are subject In wateradequacy requirements at time ofbulMin9 pemritpe/Mason County TMe a.68.
Wateruspe reaMctlons end edtlifbna/ores m apply to all new wells dolled after January 19'",2018per ESSB 6091.
7 � 7-��-
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In I[(( ran, \t 'LIf 2.3
d ❑ Driller on Site?
b ;�] Is the well capped and Vented?
rQ /❑ Is there evidence,of a surface seal? ; cu
❑ is there a 2-annular space on all sides of the casing? f'
❑ Has the seal slumped? 0. 0 (ICI :i 0 423 ;P1
❑ Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water?
Is there evidence that the seal is at least 18 feet long?
J;S ❑ Do the well site set-backs appear to be appropriate?
Comments
14%Pass ❑ Fail Inspector Date IIIe1I'wLam,4
This form may be scanned and available for public view on the Mason County Web site. Rwis 3 019 cl.
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