HomeMy WebLinkAboutWEC2025-00004 - WEC Application - 1/13/2025 {JW'f 3 Bgra)?E "
MASON COUNTY 415 INSHEL ONE 360-427-9670 EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467,EXT.400
ELMA:360482-5269,EXT.400
mudi�svwo.s.r,.,:o,,,,,.md n.dmca,.,..,rowds FAX:360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Insinuations
1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number dW:5- 001 2. Attach a plot plan and vicinity map.
-1^'U`z_'5I . ❑ Cash 3. Submit this completed application with appropriate fee a minimum
(Jl.�-�J'r >r Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment el i3"25 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification
Site Address (/y F g✓ as Td nR-- Start Card#
Drilling Firm rttIi-� ��ccffD��� O�l/ldr Phone 'Ob-Z,�S �ii�7'i�
Applicant �Fv[ nmo Phone 11� Rho DI.I.L t[
Mailing Address V61731
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City N 1n State w A- Zip
Parcel Number 2
Directions to Site figs^y1 f, 7 mot!ftyjh1gg -oL yC wef-+
Is the well site within 100 feet of salt/seawater? []Yes 1L1No
If yes, a variance from DOE is required. Have you applied!(received(circle one)a variance? ❑Yes ❑No
NOTICE:ANpmpo"d connections to new wells ere sublet!w wateradequacy requirements at Bme albullding pemvt per Mason County Tithe 6.68.
Water usage restrictions end adtlidonal lags may eppty fo eN new wills ddlled altar January 19`.2018per ESSB 6091.
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Applicant/Agent Signature
JAN 13 2025
PART 2: Health Department Review(Staff Use Only)ry l , ' LIy
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NO TAG# Called In BY'��� f_ 62 �_�71
❑ Driller on Site?
��(I ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
Lt6 ❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ® Has the seal slumped?
❑ in Is the well flowing or is there evidence of other leakage? tWl �ILL.QFAiS
❑ n Is there evidence of cascading water? '
will, - ❑ - ❑ Is there evidence that the seal is at least 18 feet long?
RI ❑ Do the well site set-backs appear to be appropriate?
Comments
Pass
Ip Pass ❑ Fail Inspector Date Gf/IZif fu Its) __
�l This to may be Manned and available for public view an the Mason County Web alb. Revlsed:2/7/2018
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