HomeMy WebLinkAboutwec2017-00128 - WEC Application - 12/12/2017 MASON COUNTY IECEEVZ
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` COMMUNITY SERVICES 11 DEC 12 2017
Building,Plenninry Er ironmental Healtk Community Health BY:__4z�,
415 N e Street, Bldg 8, Shelton WA 98584, ��
Sheltom (360)427-9670 ext 400 4, Belfair: (360)2754467 ext 400 Elms: (360)482-5269 ext 400
FAX(360)427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
�WF,Cs_, Receipt Number 2. Attach a plot plan and vicinity map.
(� q Cash 3. Submit this completed application with appropriate fee a
heck 1 minimum of 24 hours in advance of initiating well
/� construction. Refer to Mason County Environmental Health
Do I.�Y7 - Date of Payment fee schedule for cost.
4. Mason County Public must receive notification at least 24
hours Prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
Site Address 640 E Island Lake Or Start Card# WE28670
Drilling Finn Advanced Drilling LLC Phone 360 273-7735
Applicant Brad Wilson Phone 360490-2837
Mailing Address 100 E Lily Pond Lane
City Shelton State WA Zip 98584
Parcel Number 32006-50-04016
Directions to Site E Brockdale to E Island Lake Or Left on Island Lake Dr
Is the well site within 100 feet of salt/seawater? Yes No
1If f va an from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ❑No
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A plicant I Agen ignatu
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water? V
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate? 1 (� 1
Comments Will (pi�i..� 1DF A�a*o- L. Na ra I..xl L, - Aja+ rh
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site.
7:\EH FomaslDRiNKING WATER FORMS�Drinking Water Notice of Intent to Construct a Well.docx Revised: 120/2017
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