HomeMy WebLinkAboutWEC2025-00023 - WEC Application - 8/6/2025 NEci-EvE
,.,N FEB 2 4 2025 , ' N 6TH STREET, SHELTON,WA 98584
i i^;, MASON COUNTY SHELTON: 360-427-9670, EXT.400
1 , COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
! �/ ELMA: 360-482-5269, EXT. 400
\° d` Building,Planning,Environmental Health Community Health J FAX: 360-427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number ZOL'S- 2. Attach a plot plan and vicinity map.
ZO 15- 0 Cash oo07 3. Submit this completed application with appropriate fee a minimum
l t' Check of 24 hours in advance of initiating well construction. Refer to
Z� �f Mason County Environmental Health fee schedule for cost.
Date of Payment 62'27 -Z 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 76 3 s% OLD A R-C 4O i 4 /1-0 Start Card# W i= r F91,76
Drilling Firm f}4ZC41) i6 0R ILL,If✓G� 7,VG Phone 3E0 `i90 6 7C (
Applicant Rc2 G-E.12 h Y t'l f Y 7 1-1 1 A N Phone
Mailing Address 76 3 S C O L D A-t,2C t% ail Rn
City S l I F L70 'V State VW 4 Zip 9 ?S 7`(
Parcel Number 3 20 ZZ " Li ` 70 I L/ Z
Directions to Site C/1) 0t✓ /'RC4014 p.17 1-EF7 oW a' Li:(2- 946,117 O4 0L04 -Cti010 ,
If't_?� TN DP-1 Vs w47 M4I2K1O 741 i Sie(c'n.D tic,fAC an/ t-LF'r-
Is the well site within 100 feet of salt/seawater? ❑Yes 0,No
If yes, a variance from DOE is required. Have you applied /received (circle one) a variance? ❑Yes [No
NOTICE All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restric ns d dditional fees may apply to all new wells drilled after January 19',2018 per ESSB 6091.
pplicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # a Q
G 1\i Called In (---'21I2% 030 '2.,•,,
❑ ,...E' Driller on Site?
.I2--- ❑ Is the well capped and Vented?
2' ❑ Is there evidence of a surface seal? AI. ?-o 1 2-3D1
2- ❑ Is there a 2" annular space on all sides of the casing? -
' ��, 0� q (�
CI ,0- Has the seal slumped?
❑ _Et' Is the well flowing or is there evidence of other leakage?
❑ 2-- Is there evidence of cascading water? oby��,�cd
❑ CI Is there evidence that the seal is at least 18 feet long? Plot
Jur ❑ Do the well site set-backs appear to be appropriate?
Comments "lot C `l 1
Pass ❑ Fail Inspector i144444tAILLA Date gf(4
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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