HomeMy WebLinkAboutWEC2024-00018 - WEC Application - 2/1/2024 era STREET.SHELTON.WA 98584
MASON COUNTY 415 N SHEL ON 360-427 9670,,EXT.400
0 COMMUNM SERVICES BELFAIR:360.2754467,EXT.400
ELMA 360-482-5269,EXT.400
uta.aa...iar..m xma.c '^"sre FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number - Pavment Information Instructions
1. Complete Part 1.Incomplete applications will be rejected
WLC Receipt Number 2. Attach a plot plan and vicinity map.
d� ❑ Cash 3. Submit this completed application with appropriate fee a minimum
$7 Check of 24 hours in advance of initiating well construction. Refer to
.,r Mason County Environmental Health fee schedule for cost.
Date of Payment 1 4. Mason County Public must receive no6flcetion at least 24 hours
prior to the drilling of Me well.
PART 1: Applicant I Parcel Identlffcari ,6�C//144r / W�rn���9 SSa8 -1
Site Address �Ln� lv�E !l Ogli R{1779C W Start CardA 3 c�
Drilling Firm r1jrA /Y)A � Io h "/—if// Phone "1 d
Applicant 111111L/AM ASA 2 Prune <106' y9@ - `/b 89
Mailing Address /�Le cqc
{7c
City li state Zip M-01
Parcel Number 3 d 2.13 1 a n 13 n
Directions to Site
Is the Well site within 100 feet of salt/seawater? ❑Yes SNo
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ONO
NOTICE AM proposed/connection to new wens am subject to wateradequacy requirements at acre ofbufldit Pend per Meson Counly Title 6 68
Wa,,: V ✓ r sa�al lees my apply fo all new wells drAled ener January 19-,2018 per ESSB W91.
Applicant/Age/'Yiigg//oaau'I re
PART 2: Health Department Review(Staff Use Only)
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YES NO TAG III Call In 31 t,SA" Fu 3I lB Izy I Pm+
❑ ❑ Driller on Site?
❑ ❑ Is the Well capped and Vented?
❑ ❑ Is there evidence of a surface seal? z
c
❑ ❑ Is there a 2"annular space on all sides of the casing? �
a
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage? h
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the Well site set-backs appear to be appropriate?
Comments AI 7- lNc5 PgCZ-15�
❑Pass ❑Fail Inspector Date
ThMrotrn may be scanned and available for public view on the Hawn County Web site. Revised:2/7/2018
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