HomeMy WebLinkAboutWEC2023-00069 - WEC Application - 7/25/2023 15 N BTM STREET,SHELTON,WA 98584
MASON COUNTY 0 b Z023 i0 SHELTON'it 0Z7.9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-275 4467,EXT.400
ELMA:360-482-5269,EXT.400
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NOTICE OF INTENT TO CONSTRUCT A WELL
Parmk Numhar Pawnsrrt Irrfomyakon� InatruuNona
c4'r 1. Comdata Pen 1.Incomplete epplkatlorre will be rejected
WEC Recsipl Numbera'1J 2. Attach a dot plan and vicinity map.
��s t\/lj� O Cash 3. Submit this wmpleted application with appropriate fee a minimum
.y
< m-D—or Check of 24 hours in advance of initiating well construction. Refer W
1 Mason County Environmental Health fee schedule for cost.
Date of Payment 3 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicarrt I Parcel IdentM cued"
Site Address yd 1�{J WE A . ShA(e _ Stan Card# W'r- C-201
Drilling Finn �M1/iS DYI III !�ti Phone 0 -
e�31d75
ApplicantN d Phone '/_C�i-7u- 73(O(O
Mailing Address
city -Ta.c�— Srete �— 2w °I 9�10
Parcel Number �73') Z-�1d�y f� / ��.�'�.-.Qr Okcros$'EYaN'l
Directions to Site - --ro , cubrdtRO
-7(030 NEN.S�4 `N+ r�ia
Is the well site within 100estof salt/seawateR ❑Yes MNo
If yes, a variance from DOE is required.Have you applied/received lcircle one)a variance? Oyes CIN0
NOTICE:AN proposed conrmc6003 to new wells are subject to wateradenuacy mw1rements m time at bw'Idirc pe`ms I`ar Meson County"'s 6.68.
Wafer usage reatdc8ons and eddllbnel kes maY eppty to ell rew woes OMled seer January ta^,2018per ESBa BOaf.
NcAR_ ►S, s � R�
Applicant/Agent Signature
PART 2: Health Department Review Staff/IU�see'Only)
YES NO TAG# 8 Q (65 Called In
❑ Driller on Site?
z Is the well capped and Vent
IGt ❑ Is there evidence of a surface seal?
V ❑ Is there a 2"annular space on all sides of the casing?
!-1- Has the seal slumped? � J/�V! I L
Is the well flowing or is there evidence of other leakage?
17 Is there evidence of cascading water?
"[) Is there evidence that the seal is at least 18 feet long?
I] Do the well site set-backs appear to be appropriate? r ,
Comments
L 5 > U ma
Pass ❑Fail Inspector Date
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This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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