HomeMy WebLinkAboutWEC99-0130 - WEC Application - 7/14/1999 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON ))WA 98584
(3 0C'u � 7798
MI WELL CONSTRUCTION PERT n
Receipt NO: L:J
Date Of Payment: =2111'1 �ft /Mfl
INSTRUCTIONS J V L ll 1:1�J
i. completePart One.
HEALTH SERVICES
P
2. PayyS40.SiO,fee end sukmit this eppl icatian a mini nem Of 24 hours in advance of initiating eanstruetlan. Make check,
payable to: Mason county Treasurer
3. Attach plot plan.
4. 24 hours prior to drilling the well, contact the health department to give notificatio of starting. Fax to: 427-
7798, or Telephone: 427-9670 ext. 358 (8:00 a.m.-5:00 p.m.)
PART 1: APPLICANUPARCEL IDENTIFICATION
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SITE HOUSE ADDRESS L L W.
(1�'/� / d
DRILLING FIRM NAME b�\I f 5J5,, _ +�/�t)��t'L /�����,� START CARD NO. W /II O 31
PROPERTY OWNER NAME W IL-L-i h-M TELEPHONE ( 1
MAILING ADDRESS
6 �9 tyif �M,i 0
ASSESSOR'S PARCEL NUMBER U
SUBDIVISION (If Applicable) p pDIV ELK _ LOT
ITE
DIRECTIONS R LOCATING S � P cK.k Y- VG!UO ITO 7`Q ✓nf
L
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK:
DATE OF ANTICIPATED COMPLETION OF WORK:
PART 2: DEPARTMENTAL USE ONLY
....................................................................................... .
TIDEMARK NO.
CALL-IN DATE ' CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/PM
TAGGING AND SEALING SATs FACTORY? W�Yes U NO
COMMENT !rE N
�... 9'�.7.r�99
INSPE R DATE OF INSPECTION
�:\uturAlAAcxrve\woes-ren.w
w ZszO 01107196
Fila On,ral with -. WATER WELL REPORT NMwMlnbnl W 111834
Department of E;oulty UNIQUEWELLI.D.a AFN 54R
S—M Copy Owrnrs Copy STATE OF WASHINGTON
Thtrd Cop) Drillers Cop/ Water Right Permh No.
(1) OWNER: Name William McCarty AEdraM 9649 Miami fl a 11 Rd- , Seabecic WA 98380
(2) LOCATION OF WELL:County Mason ;F1/4-17—im Sac-3--T13_N.R._-2W_WM
(2a) STREET ADDRESS OFIii(m nearem Address) Lilac Ln. Be fair, WA 98528
TAX PARCEL NO.: 2 2 309-76-001 20
(0) PROPOSED USE: 14 ComMal, ❑ Industrial ❑ Municgel (10) WELL LOG or DECOMMISSIONING PROCEDURE DESCRIPTION
❑ Impaann ❑ Test Well ❑ Offs, Formal Describe by color,character,sire of material and structure,and
❑ Dewa e, the kind and nature of the material in earn stratum penMreted,wlM at Nast
(4) TYPE OF WORK: Owrrers number of well if more Man oM) one army for each mange of Information.Inge ate all water encountered.
K N.WNl MBMM: MATERIAL FROM TO
Departed ❑ Dug ❑ Bleed
Reconditioned N Carla ❑DrMn
Decommissbn D Ro cry ❑ Jemd
(5) DIMENSIONS: Diameter of well Inures
Drilled 153 feet. Depth of cawlered well 153 ft. Gray harjpan 5 4
(6) CONSTRUCTION DETAILS
Cash,Installed: Gray clay 40 45
a Welded 6 Diem.from 0 .to 148 n.
❑ Liner installed Diem from ft.0 X.
❑ Threadetl Gam.noon n.fo n
Perforations: ❑Yea X No Brown hardpan 90 96
Type of perforator aged
SIZE of perfonrons in.by M. ement sand &
—detonations from n.to Awith water
Sand IS, gravel with water ' 145 153
Sproens: N Yes ❑No M K-Pi l.aceaon 146 _-
Manufadurers Name ('.Mk
TY➢e r { Model No.
Dlam. slur sire from 48 n.lo�5j n. -
Diem. Slur sift tram n.M ft_
GrewpFlner pedred: ❑Yea Keep a sltt of grarelleend
Material placed from n.to n.
surface seat ®cos 15eYonite depth? 18 n.
Material used in scot
Did am strata wra m unusable wares ❑Yee X No
type a waters Depth M atom. HEALTH S
Maltotl of soaring mra a Mr
(2) PUMP: ManulaoMe(e Name Goulds
Type: a pub, N.P 3/4
(8) WATER LEVELS: 1u10.wNa Manger,Sipes mean sea MYN ft.
scarp lerM 95 ft.bMavepmwi Dare Workstene, 7/7A9 compiaed 7,1
AHesan preseura Ind.per sernre Into Dare
Artealan water of canmoped by
(Cep,whw,me.) WELL CONSTRUCTION CERTIFICATION;
(9) WELLTESTS: Dtawdown M amount water level is bxered bebw erect rent I commutator and/or axept responsioilM for commucron of this well,and its
Was a Pump test medal O Yea No If yes,by wTpm? ompl'unce with all Washington well construction agandards. Materials used
and Me information reported Moors are true to my best knowledge and basis.
Ykgd: _pallmin.with ft.drawdown after tn.
YNM: _pMlmM.wind n.drewdown after his. Type ar Pdnl Naml N 1 RN1Q Dn _Licensa No. 1 RR6
YIeM: pellmM.with IL dravelown after hts. (LkxraAd Uwler/Ergirnm)
Recovery dais game When As zero Man pump turned oft)(water level measured from
Tninea Name licenu No.
well top is comer fowl)
Time weer Lew1 Time wares Level Time wale.Level Ddnitg cwnpany Davis Drilling
(Bigred) .i nor llcenae Na 1886._
(Lironwd orilMnEngk,ear)
Address Belfairp WA 98528
Data of tend
palison.wigh n.draWbVln she, 1 his R goon E10fa
B.I0,end
Airrem aellmM.eft ft.impedimentafter ha. pislretton NO DA Dy�1S 1111 Dare .T1 V 94__
Aresan few a.p.m. Date (USE ADDITIONAL SHEETS IF NECESSARY)
Temperature M wand_Was a clremical entree made? 2 Yes Milo
agagnpy a an Equal s,bo dell and AXe Resources,
rces, employer.at For specal
a RX).Us D needs,wnrea the Water Resources Program m (B(0)407-
ECV oso 1 m It trml 8800.Tne MD number a(:Nrro)407-60m1