HomeMy WebLinkAboutWEC2025-00009 - WEC Application - 1/17/2025 Ta No yam„ LK
415 N 6Ta STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,l400
COMMUNITY SERVICES BELFAIR:360-2754467,EKE 400
ELMA:360-482-5269,l 400
aaayrrneyemw.""+aura� ^ma�aa FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
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PavmeM lMormetlon Instructions
1. Complete Part 1.Incomplete applications will be rejected
W Receipt Number 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate tee a minimum
Check M 24 hours in advance of initiating well wnI=en. Refer to
� ��� ����� Mason County Environmental Health fee schedule for cost.
�ra(l Date of Payment_JL/y;(Yf 4. Mason County Public must mwive notification at least 24 hours
`` --lI �(�� ��11�-�� l prior to the drilling of the well.
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PART 1: Applicant l Parcel Identification /601. tJE / Lv"-fti1AVidt7bR
Site Address w� e,�._�f.� T/Y.LEf'S startcard# �/FSS"69H
Drilling Firm Cma/&A r Or : 1 /:>7x Phone 3�1m- &3o
Applicant - 9e�mo—
?I"a yDY /1�1G Phone c3 �D •�ey- B 3
Mailing Address /XVG-
City p ee h7 6t+aph state /f/0. Zip ogt3) a
Parcel Number l��m !� . /�
Directions to Site Su Q{/'4c�]!� 1164�TM t'7Aa�/�" Lk 24 J- ai^
Is the well site within 100 feet of sale I seawater? ❑Yes Olgo
if yes,a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes Ohlz—
NOTICE:All proposed chant M new wells are subject to weteradequsey requirements at time offnadding pam l par Mason County TWO 6.68
Welerusage mVncY add@o' nal fa_es all new walls drilled after January 19tl1,2018 per ESSE 6091.
Applicant l Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
e�or�1
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2•annular space on all sides of the casing? l�ryljlfl
❑ ❑ Has the seal slumped? JAN 17 2025
❑ ❑ Is the well flowing or is there evidence of other leakage? ;
❑ ❑ is there evidence of cascading water? BY---------------
Cl ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments L&T 1
❑Pass ❑Fail Inspector Date
This form may be scanned and available for public view on the Masan County Web site. Revised:2/7/2018
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+ 22319-50-00904 X Q
Parcel Number
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