HomeMy WebLinkAboutWEC2025-00005 - WEC Application - 1/13/2025 6lZaIrEV(E 6Zi - $TR>rTCH tst AA
415 N BTM STREET,SHELTON.WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-482-5269,E)CT.400
e.ra,ar.�:arwaom.roaxwmc� xvxww FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavment Informatbn Instructions
1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number LMZ -LU83 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
J3(, Check of 24 hours in advance of initiating well construction. Rehr to
6b005 Mason County Environmental Health fee schedule for cost.
Date of Payment 1 -1 j5 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Parcel Identification ,,, (� c- c�
Site Address l(o) I S i cArA Gr es+rA Start card# W t S y L068
Drilling Finn V r-I Ili _ Phone
Applicant 1010 �'er Phone
Mailing Address 357Z5 Z7f"
city Wa4
[� state W gd
_ zip °1 WO3 / 7
Parcel Number Z[O 'I S — c) I o
Directions b site Wen 1 Skt e el, 1 s la ri..Ad 1l is ke l s f m h CrP�{- b �(
Is the well site within 100 feel of salt I seawater, ❑Vas IEINB GKE RT �� � L otJ JIl4'-�GI> )+) 1"
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ONO 5��95
NOTICE'All proposed cunnecilons to raw,wells ere subject to weteradequecy requirements et time ofbudding penst per Mason County ride 6.68.
waterusage minctions annddaad/dtNo fa fees may apply to as rrew,wells drilled afterlanuary 190,2018per ESSB 6091,
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# *47 Called In rpI Z-JIZS Fo#L tl I
Ly 11.57
❑ Driller on Site? (,a�1 tt ;L`Lrf
❑ Is the well capped and Vented?
AOE ❑ Is there evidence a surface seal?
❑ Is there a 2'annular space on all sides of the casing? � V
In ❑ Has the seal slumped? rM'
Is the well flowing or is there evidence of other leakage? �pN 13
❑ Is there evidence of cascading water?
J C❑ Is there evidence that the seal is at least 18 feet long? `
❑ Do the well site set-backs appear to be appropriate?
CommentsSi'�Pi�nO
Pass ❑ Fail Inspector Date ZI n Z-oz S
This farm may be waned and available for public view on the Mason County web site. Revised:2i72018
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