HomeMy WebLinkAboutWEC2023-00137 - WEC Application Doc chccK* 3Z11 16131/23
MASON COUNTY 415 N SHELTON:360427-9670 EXT.400
COMMUNITY SERVICES BELFAIR:360-27Ti4467, EXT.400
ELMA:3604825269, EXT.400
FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Pan 1.Incomc:ete applications will be rejected
WEC Receipt Number aal 2. Attach a plot plan and vicinity map.
❑ Cash yg5-, 3. Submit this completed application with applolOnato fee a minimum
Check of 24 hours in advance of initiating well core traction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 11 I Y 19.1 4. Mason County Public must receive notificeton at least 24 hours
Op 3� I—I'7T" ac prior to the drilling of the well.
PART 1: Applicant/Parcel Identification 3301 uE
Site Address L1ri 1 AIT neAmaYn Renck Rn Stan Card# In/E t,4 89 R
Drilling Firm �- Phone (s(m)7 75 '536-7
Applicant 1 DIN[lr+ jnt5 Tnfr_ Phone (Qc�.)ZU -7 a7
Mailing Address Pei. Rn X 755
City B�14:;l r State VVA Zip I st �2)C
Parcel Number 3�3�FS LI �000 �r7
Directions to Site klnA rn klC- L:6,k4 c Rn A� rYd ea l rFF-Q_nl R bTOi is
Is the well site within 100 feet of salt/seawater? ❑YesNo
If yes, a variance from DOE is required.Have you applied'/received(circle one)a variance? ❑Yes ❑No
NOTICE:Aa proposed connections M new,wells are subject to wateredequacy requirements of fine Of building permltpor Mason County TIOe 6.6e.
Water usage restrictions and additional fees may apply to all new wells drilled aBerJanuery 19a, 2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In t1 1t.12i Fmr- ll lip I23
❑ Driller on Site? laplap M mar
Is the well capped and Vented?
R°J Is there evidence of a surface seal? I . f
❑ Is there a 2'annular space on all sides of the casing? ulJ.'7 m
Has the seal slumped? 041 -1111%37240
❑ Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water? , y�
Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
m s oments " 1 Z 6 i ry�
IyJ Pass ❑ Fall Inspector Date I��Z� �C✓Z;
/ This form may be sunned and available for public view on the Mason County Web site. R"iwd:2/7/2018
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