HomeMy WebLinkAboutWEC2024-00121 - WEC Application - 10/25/2024 M t}Af,5-0 M le-
5 11
684
MASON COUNTY Il1I}l�! NSH N STREET,SH27-967 ,E T.400
COMMUNITY SERVICE OCT 2 5 2024 BELFAIIR:360-2754467,EXT.400
e�+dnsn..,:ar wm,w x.au,.ca�u,Mrwla ELMA:360-4825269.EXT.400
By FAX:360427-T787
NOTICE OF INTENT TO CONSTRUCT A WELL
Petal N= Payment Information Instructions
1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number &Z-q-a'1521 2. Attach a plot plan and vicinity map.
20• 4_60(2( ❑ Cash 3. Submit this completed application with appropriate fee a minimum
❑ Check ( of 24 hours in advance of initiating well construction. Referto
Date of Pa merit ��- ZY Mason County Environmental Health fee schedule for cost.
Y 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 /9V F 54 Ed 1� Stan Card n
Drilling Finn e�d"allyafee r{!/f•' �.h/. Phone
Applicant 1�/t,�kRw ��h//Irl� Phone ��- Gd� -4,�7/
Mailing Address 5L.T
city stiel Ah state zip
Parcel Number ,?
Directions to Site
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 ❑K5�
NOTICE:Aepmpossed connections to new wefs are subjecf to wateradeguacy requirements at time of Wilding pemxt per Mason County rde soa..
Wale-usage nishictipfftyd additional laes may applyf,aN crew wells ddllad afar January 19',2018 per ESSB 6091,
J
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
q YES NO TAG if Called In l2'3D IZt*VL�` ` I25-
Driller on Site?
Is the well capped and Vented? "
❑ Is there evidence of a surface seal? a n 6d, -"`C-
a Z " c
. ❑ Is there a 2"annular space on all sides of the casing? 4 f 4(rs(.-I
❑ ❑ Has the seal slumped?+14c' SbQ 4 rf,
❑ ,Er 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?
,e` ❑ Do the well site set-backs appear to be appropriate? 4
, - a
Comments S6W�1,( Cq-,r6 ,4( N `Irytyl,�- TL- a
❑ Pass ❑ Fail Inspector / �Date 7 9 S—
This form may be scanned and available for public view on the Mason County Web site. Reviwd:V7/2018
t
lit
lip
d �
x J/
R
a
o
R 2 �-