HomeMy WebLinkAboutWEC2025-00030 - WEC Application - 3/5/2025 :„ D EC-E- ilwmr
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4;;c "'kwr _ MAR 0 25 (, 415 N 6TH STREET, SHELTON,WA 98584
;\ MASON COUNTY SHELTON:360-427-9670, EXT.400
��' �,1 COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
t,=;, ✓,.i - , , *�j� ELMA: 360-482-5269, EXT.400
v Building Planningf nvironmental Health.Community Health B
n._ ,,, ,,,� FAX:360 427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number ti SO5 2. Attach a plot plan and vicinity map.
202 5 0 Cash 3. Submit this completed application with appropriate fee a minimum
V`C Check of 24 hours in advance of initiating well construction. Refer to
00030 Mason County Environmental Health fee schedule for cost.
Date of Payment 63 05'15 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 0 Highland Rd, Shelton Lot 1 Start Card# WE59046
Drilling Firm Advanced Drilling LLC Phone 360 790-7373
Applicant Dahl Properties Inc Phone 360 410-9524
Mailing Address 261 Hamilton Rd
City Chehalis State WA Zip 98532
Parcel Number 520241350010
Directions to Site W Shelton Matlock Rd 8 miles to W Highland Rd. Parcel on left
Is the well site 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
NOTIC7 .moos on ections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
ater, •••• re ric s d additional es may apply to I new wells drilled after January 19`h,2018 per ESSB 6091.
Ap icant/ ent Sig Lure
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # P N b-) 2— Called In a(l i(Zs c eq.-4. 3\ 1 3 zS�
❑ Driller on Site?
.Et ❑ Is,the well capped and Vented?
£t ❑ Is there evidence of a surface seal?a- ❑ Is there a 2" annular space on all sides of the casing? 4 , Z t o 44 g S_
❑ B' Has the seal slumped? — ( 2 5 2.2 co
[2-. 0 Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? lJ c T " i3 5` n e 121
et ❑ Do the well site set-backs appear to be appropriate?
Comments /
-B Pass ❑ Fail Inspector �'✓i4 ! Date 3 z 02 J
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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