HomeMy WebLinkAboutWEC2021-00101 - WEC Application - 5/3/2021 TA;_w y A
415 N 67H STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR.360-275-4467,EXT.400
ELMA:360482-5269,EXT.400
FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number- Payment Information Instructions
1. Complete Pan 1.Incomplete
lete applications will be rejected
W EC Receipt Numbee&- 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
IP Check o124 hours in advance of initiating well construction. Refer to
1 •Tj Mason County Environmental Health fee schedule for cost.
OitaO l G
l Date of Payment 4. Mason County Public must receive notiecetion at least 24 hours
prior to the drilling of the well
PART 1:Applicant I Parcel Identtiiffiilcationn�� �. J y/� 2''7
Site Address p I /1 I I4R1/ VV d•• , FA Start Card# W� ✓c 1 �7
Drilling Firm - Phone Y� h�( 0
Applicant � a 0Uz ('�P,hone ZJ1GZ( 7O
Mailing Address r�� 70 E ZLP
City f�t'dW -mot State �_ Zip l 90 C�
Parcel Number Iz3o5- �O-DO025
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑Yes,QJNo
If yes, a variance from DOE is required. Have you applied I received(circle one)a variance? ❑Yes ONO
NOTICE:All proposed connections to new wells ere subject to wateredequacy re0unsrnenfs of time orbaldirg permil perhf m County Tine 6..68.
Waterusage restrictions and adddwnal foss may apply to all new wells dnlled after January 19",2018 per ESSB 6091.
Applwant/ gent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In I t'Kit f I4I LS
Driller on Site? Yn 9 o I T S
❑ .2r, Is the well rapped and Vanted? 14-1• SK 4 7
2r ❑ Is there evidence of a surface seal?
(Zr ❑ Is there a 2"annular space on all sides of the casing? O �'
❑ f ' Has the seal slumped? U
❑ J2' Is the well flowing or is there evidence of other leakage? MAY U 3 2021
❑ Is there evidence of cascading water?
❑ Is there evidence that the seal is at least 18 feet long? 6y
❑ Do the well site set-backs appear to be appropriate?
Comments t,ocwk A 4 "r. � 1T 1 ke iii
PT'Pan ❑Fail Inspector Date
This form may be scanned and available for public view on the Mason County web site. Revised:2/7/2018
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