HomeMy WebLinkAboutWEC2024-00005 - WEC Application - 1/2/2023 415 N 6T"STREET,SHELTON,WA 98564
MASON COUNTY SHELTON:360427-9870,EXT.400
0 COMMUNITY SERVICES BELFAIR:360-2754467,EXT.400
ELMA:3604825269,EXT.400
waa�y w.nnarnwanm<maxnuhcmn.+nigaw��F FAX 360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Perm't Number Payment Information Instructions
1 '�� 1. Complete Pan 1.Incomplete applications will be rejected
e� Receipt Number 3. Attach a plot and vicinity map.
1 ❑ Cash 3. Submit this completed application with appropriate fee a minimum
.m Check of 24 hours in advance of initiating well construction. Refer to
4 [" Mason County Environmental Health fee schedule for Mgt.
UV�b Date of Payment A'�•• 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 A lt. Start card# I J F C2(93U
Drilling Firm U Phone ry
Applicant Phone
Mailing Address CRY zd
State _ ZIP —R1 00
7
Parcel Number 7 zt— SV-090)
Directions to Site l`fg f1"r<�nu/ r. 3 a d � a` � Nye`'` P i��g''� I'��` )��
/'d✓`r bCl'�t-r••V�.
Is the well site within 100 feet of salt/seawatel. ❑Yes 56o
If yes, a variance from DOE is required. Have you applied received(circle one)a variance? ❑YesINNO
NOTICE:Alt proposed c ne s to crew welts are sub/ect M wateradequacy mquhements st time oftiulMing permit per Mason County Ties 6,68.
Water usage rashfl tl8ional fees may apply fa all new,welts dneled after January 1r,2018 per SSSBi0gl.9 7,
zo17�y
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Applicant/Agent Signature
,
PART 2: Health Department Review((SStaff Use Only) \
YES NO TAGTAG# : f G 1 Called In
N t 3�"✓� �dri(de l S�roIZ3
❑ Duller on Sae?
or ❑ 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?
0 Pr Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage? I{
❑ Is there evidence of cascading water? JAN 02 2023
�/QFO�I ❑ ❑ Is there evidence that the seal is at least 18 feet long?
1pl� ❑ Do the well site set-backs appear to be appropriate? By
Comments 3 1• p#ytj`( wCU-5 D7j cW0 bn) 37.os1. 6- ot—_--�---
[yPass ❑Fail Inspector Dale Z
This form may be scanned and available for public view on the Mason County Web site. &evised:217/2018
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