HomeMy WebLinkAboutWEC2023-00023 - WEC Application - 2/27/2023 . .._.. --_..-.. .... . _-... ..
415 N 6TM STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:36D-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467,EXT.4D0
ELMA:360-482-5269,EM.400
a,ugryway r,iwmm�„yxwrte�,..,pxra FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
permk Number Payment IMormadon
�. Complete Part 1.In mplete apDlicatlons will be rejected
WEC Receipt Number AY11rQ1 ;- Attach a plot plan and vicinity map.
rtr�r���iy.H,t q ❑ Cash Submit this completed application will appropriate fate a minimum
HHrr IM X<J �B. Check 41124 hours in advance of initiatlng well construction. Refer to
Mason Count Environmental Health fee schedule for coal.
Dale of Payment 4. Mason County Public most receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Parcel ldwdMceflon
Site Address /v - h OVf VA -/ Start Card# w L" jd Z-
DrillingFirm payli5 T/r 1 � ^o / Phone 3Cd0 'ZZ.r-��7
Applicant /j VV LOQ91!2Z - Phone
Mailing Address LS Zy n/ �P�-g�}o! 54- 2MR Is-
city 7A Slate w'ft- zip
Parcel NwIdw 32 3332 2-0Uo3 cb
Directions bite L-&-t ct cr zS -fro�rl �i� blawe -�tnlP, Wes{- /I.� S h o✓'<.PJ�
1,vC, CGmba IQrfb an t� s�+I/ij
ISVW we*site within 100 feet of SSR/seawater? ❑Yea No
tlyes,a whence from DOE Is required.Have you appNed AA received (circle one)a variance? ❑Yes ❑No
NOTICE:Aepmpmedwn tlwrsbnewant§eresubjecttowereredeeuwyreo*w faMtimeofbuildlrppwmifpm Meade CountyT 6.66.
Weferrwpeteefrtcanna and edda'Mes,"may epply to all new wells driYetl efle,J111 y or,2018per E55a 6091.
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ApfiCeld/Agent Signature '�a (� 6F FEB 27 2023
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PART 2: Health Department Review(Staff Use Only)
BY
YES NO TAG# Caged In 4!.'I
1yA
0 ❑ Driller on Site?
❑ ❑ X Is the well capped and Vented? C?PTf 1990
❑ ❑ X Is there evidence of a surface seal?
❑ ❑ k Is there a T annular space on all sides of the casing?
Has the seal slumped? /L I >
❑ �J Is the well flowing or is there evidence of other leakage? W'1 2).076 I0
7L/
❑ fyR�I Is there evidence of cascading water?
'IJ Is there evidence that the seal is at least 18 feet king?
❑ Do the well site set-backs appear to be appropriate?
Comments PER gwV 2l tl T rf-t6W G ill PtheE.
Pass EllFail Inspector Date Y12S/L 23
This form may be scanned and available for public view on the Moon County Web lift Revised:NA2018
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