HomeMy WebLinkAboutWEC2024-00013 - WEC Application - 1/22/2024 i
415 N 6TM STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360427-9670,W.400
0 COMMUNITY SERVICES BELFAIR:360-2754467,EXT.40O
rmsw,n:gu.,.w.„wrrxwx.�.n,.,mx,.xn ELMA:360-482-5269,EXT.40O
FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number 3 2. Attach a plot plan and vicinity map.
y a � ❑ Cash 3. Submit this completed application with appropriate fee a minimum
XD Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 4. Mason County Public must receive notification at least 24 hours
a.Z. prior to the drilling of the well.
PART 1:Applicant I Parcel Identification
Site Address 1Z0 nlIP '1iG-PN WrAl F. Start Card If WSJ J3'1 �
Drilling Firm V 4. 9 ftQ4 � Phone 0^ o N
Applicant AA,A+ 1( 11L1( Phone �Ndo Z
Mailing Address
City V1e1-FalIr state 1n1 zip 01 Z
Parcel Number
Directions to site oaf C,f.�awai _,�22�}�_ , �Cytl Z QYl '
Is the Well site within 1 DO feel of salt/seawater? ❑Yes *0
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? []Yes ❑No
NOTICE:All proposed cnnneclions to new wells are subject to weteredequ.cy requirements al time albuilW'rg pemulper Meson County Title 6.68.
Water usage restrictions aW addiM1 nel fees may apply ea new wells drilled after Januery 19^,2018par ESw M.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# "B'PQ It B Called In J'j1't j'-t f. ' t11
❑ Ter Driller on Site?
❑ Is the well capped and Vented? f}7. So141 B
❑ Is there evidence of a surface seal? LotS(r : _(ZZ,�633`tp3
❑ ❑ Is there a 2"annular space on all sides of the casing? c&Set2VE�
4T ❑ Has the seal slumped?
I* a' Is the well flowing or is there evidence of other leakage?
❑ j2w Is there evidence of cascading water? '
❑ ❑ Is there evidence that the seal is at least 18 feet long? r oSSL*R �
❑ �" Do the well site set-backs appear to be appropriate?
7
Comments W4 o �
❑Pass ❑ Fail Inspector Data
This form may be scanned and available for public view on the Mason County Web site. ReAnd:217/2018
Mason County WA GIS Web Map
•
Y /
• y/
K
y� xy
xw .O
1/18/2024, 10:58:36 AM ✓� V 1:1,527
Z0 0.01 003 005 MI
IJ County Boundary '0 0.02 DaN 008km
No Filled
Site Address (Zoom in to 1:3,000)
W N:Esn.NERE.G- . .IGN.p.FlO6r tPl.0 GEBCvUSES.
J O NPS.1.E. ..(. . -, (of 0 ,NL ON rvry E.
Tax Parcels (Zoom in to 1:30,000) GSvu,rIC ro f^�'" "mp' "'op" "° °"M`.
Mwn C"uMy WAGIS WW,MapAg 00o
Count,of l oMp,9umau o U,d Maregemenl,EM Cm ,E n XERE,Gvm'm,INCRE,'EM P USGE.EPA,USGA I