HomeMy WebLinkAboutWEC2023-00063 - WEC Application - 6/8/2023 . t
JUN 05 2023 415 N 6TM STREET,SHELTON.WA 98584
MASON COUNTY SHELTON:360-427-9670.EM.400
COMMUNITY SERVICIFS BELFAIR:360.2754467,EXT.400
— ELMA:360,M-5269,EXT.400
au„an.,,,.,v Envy-MI-LW11 ccmnunnYaWY, FAX:380d27-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
Psmrk Number vmem Inbrmstltm Instructions
1. ConpMs Pad t.Incomplete applications will be rejected
WEC i: t Number ab- I� 2. Atitwh aow Wan and vidnity map.
Cash 31 Submit tles completed application with appropriate fee a minimum
�a� Chi of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule br cost.
G38(03 Payment 10 8 � 4. Mason County Public must receive notification at least 24 hours
pnor b the drilling of the well.
PART 1:Mp�nt I Parcel IrlmttiRoatlon ' 1
Site Address 1'1 O S A/E Qt Wcnth fz lj Start Card# W b_pS, `�s Co
Drilling Firm ck y I s T)V I ( If, P�) PhoneApplicant Det9ir-C 1—I.�W f C� Phone
Mailing Address To 'gd X 7U ( -
City RQ .j1L1 I r state %Aj _ zip 8S7
Parcel Number �7 rI'0U'
Directions to Site 'r OY✓� -1'PQ IAV-2 �y7N�'It1Ul Dn V�P.WQU IU�S't"
6(0�,1- {nor o pewatb but f K91 , on L
Is the well site within 100 feat of sale l se8wabr? ❑Yes ONO
if yes, a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ONO
NOTICE:All propwedconnectic.to new wells are subject to weteradequwy requirements et time 9balldln9 pemNper Meets Coraky TWO 6.68.
Water uaape resalceonaendaddltiorolfee ayapptyro se raw wane Mled same January W,2018 per ESSS W91. —
Applicant/Agent Signature
PART 2:Health Department Review(Staff Use Only)
Celled In (o IlkI fc ` y,(5 Its
YES ,,Nyyy,,4O11 TAG# --I
El Driller on Sib?
❑ Is the well capped and Vented?
Is there evidence of a surface seal?
�❑7I Is there a 2-annular space on all sides of the casing? I
El Y' Has the seal slumped?
❑ ® Is the well Flowing or is there evidence of other leakage?
❑ p❑r5+ 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 ppmpriate?
��co''mments RIG -� �II , IW, I I 1 /��(7
IAt Pass ❑Fail Inspector Date —3—/ i f L 0 VA
This farm may be scanned and available for pudic view on the Mason Ct urty Web sift:, Revised:2/7/2018
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