HomeMy WebLinkAboutWEC2023-00129 - WEC Application - 11/30/2023 0
415 N fir"STREET,SHELTON.WA 98584
MASON COUNTY SHELTON:360427-9570,EXT.400
COMMUNM SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-4825269, EXT.400
FAX 360-427-T787
NOTICE Of INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
W EC Receipt Number 2. Attach a plot plan and vicinity map.
aoa3 ❑ Cash 3. Submit this completed application with appropriate fee a minimum
r Check of 24 hours in advance of initiating well construction. Refer to
V O 1r1(� Mason County Environmental Health fee schedule for cost.
h
d--1 Daft of Payment tjj } 4. Mason County Public must receive notification at least 24 tours
prior to the drilling of the well.
PART 1:Applicant I Parcel Identification
Site Address 360 E Wa1tBr Scott Drive, Shelton Start Card# WES4649
Drilling Firm Advanced Drilling LLC Phone 360 273-7735
Applicant KCV�0 4�u NOkW\ — "aN-\S?J(1 Phone 802349-3231
Mailing Address 360 E Walter Scott Drive
city Shelton State WA Zip 98584
Parcel Number 22013-11-50240
Directions to Site Harstine Island Bridge/Righttthen left onto E Island Shores Rd/follow to end/up _
dill Rd turns to Walter ScotUtst driveway on left after Kad Scott Lane
Is the well she Within 100 feet of salt/seawater? []Yes ®No
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes []No
NOTICE:All proposed connections to r�ew wells are subject to water atl v racy re4ubements of time of building permit par Mason county Title 6.66.
Water wage mxmictionx and addli onal fasa may apply to all raw wells dulled afar January 19",2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 1f29�2-3 FwL t `3oIZ3
❑ Driller on Site? T� tig3o
❑ Is the well capped and Vented?
❑ Is there evidence la aysurface seali �Le4l�Le!!S V J.Cd ll ll a
❑ Is there a 2' annular space on all sides of the casing? fI)II,,�I,flp D
❑ GtJ Has me seal slumped. OCT 23 2023 L��J� N
❑ Is the well flowing or is there evidence of other leakage? ,7
❑ Is there evidence of cascading water? BY_ Z.
❑ E] ii Is there evidence that the seal is at least 18 feet long? /1r ----� CIX
(F ❑ Do thewell site set-backs appear to be appropriate?! �r•�'1�( I S'
���Comments 5L f A fit V, 7 � evlr W&I rik,
Pass ❑Fail Inspector Date -�3�/�(/
This form may be scanned and mailable for public view on the Mason County Web rib. Revtscd:2/7/201S
( 4f: 41-aL5p(
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