HomeMy WebLinkAboutwec2024-00003 - WEC Application - 1/3/2024 415 N 6Ta STREET,SHELTDN,WA 98684
MASON COUNTX SBELT I 380427-9670,EXT.400
SVI�S BELFAIR:360-2754467,EXT.400
ELMA:3:0.4825289,EXT.400
COMM 1 FAX:360-427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
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Permit Intortnation 1. Complete Park 1.Incomplete applications will be rejected
mber 2. Mach tplat plan end vicinity map.
sh 3. Submh this completed applity ma with appropriate tee a minimum
of24hoursinadvanceofinitiatingwailconstruction. Referto
eck Mason County Environmental Health fee schedule for cost.
yme' 4. Mason County Public must receive notification at least 24 hours
prior to me drilling of the well.
PART 1:Applicant I Parcel Identification
She Address A��` Start Card# 1 F �
Phone 340 7S6. 7013
Drilling Finn r�
Applicant Phone
Mailing Address i d Al C
city State _ zip
Parcel Number 32crz(' Sv_d 101
Directions to Site v�1 i - ��✓` '„ `^ '� 4 1 /�
bc(AK .1k.
Is the well site within 100 feet of salt I seawater? ❑Yes o
If yes, a variance from DOE is required. Have you applied I received(circle one)a variance? ❑Yes�RNO
NOTICE:AIIprePas?dc ne to new wells are subject to water adequacy,requirements at ame ofbufMM9 parmk per Mason County Ties 6.66.
we usage lea r 'tldbrealless may apply ro all new welts drilled alter January 19e,2018 p rES B6091.
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pplic urn/Agent Signature ;z,9: 6ocai y
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# N t'G 1 Called In
❑ Driller on She?
Is the well capped and Vented?
_❑ Is there evidence of a surface seal?
❑ recausing?
Is the a 2'annular space on all sides of the causing?sing? UIUI
Has the seal slumped?
El Is the well flowing or is there evidence of other leakage? Jp,Pd U 3 L.1
I.there evidence Of cascading water?
�+yFOK ❑ �❑ Is there evidence that the seal is at least 18 feet long?
P ❑ Do the well she set-backs appear to be appropriate? -
Comments 3 Z—fiwrf WE/LS )Q11A0 ON 32011 -50. 0901/
1vjbesa ❑Fail Inspector , Date
This form may be sunned and avaliable for public View on the Mason country Web sire. Revised2/7/201
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