HomeMy WebLinkAboutWEC2025-00086 - WEC Application - 7/9/2025 -O L-TG Ni — 1--1 tf\1 G-t-1
415 N 6TH STREET, SHELTON,WA 98584 •
MASON COUNTY SHELTON: 360-427-9670, EXT.400
= i COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Budding Planning Environmental Health,Commumty Health FAX:360-427-7787
. NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1, Complete Part 1. Incomplete applications will be rejected
WEC Receipt Numbest —6 2. Attach a plot plan and vicinity map.
a,5 - ❑ Cash 3. Submit this completed application with appropriate fee a minimum
tr Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
i.°fb(p Date of Payment Z` 4G� Ic:15 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 A ✓S i's y L /l-' Start Card# 41/1-46.02S3
Drilling Firm CCP /i ,_hr 0 r •` J ( it h✓�j Phone,Woe- g-3&-g vex..)--.vex..)--.Applicant 0 yew h 17 "'// /Am --s A1, c , Phone 34e_ `Ife- l3r
Mailing Address f 9-30 cc 8 rock ode J �- /'
City �e /f-+� State . /1. G1 Zip -S,
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Parcel Number 43 A1 6 (-9 7J 0 67( 3 1 3/ 7 C9 2 74.5—949 B,3 2,
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑Yes EN-Cr
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? ❑Yes if 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 resift• and additional fees may apply to all new wells drilled after January 19'n, 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) (-2-.. y/[��
YES NO TAG# Called In 7
3 0 f-` am,
/
,,e ❑ Driller on Site?
❑ 2' Is the well capped and Vented? �y�
❑ ❑ Is there evidence of a surface seal? Ail r ' r1. 5? Vy
❑ ❑ Is there a 2" annular space on all sides of the casing? t �
lil
❑ ❑ Has the seal slumped? ;�1 ',t
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water? BY:__.__...
❑ Is there evidence that the seal is at least 18 feet long?
CI El Do the well site set-backs appear to be appropriate? 10. f l0 17(i `
ID
Comments Lynch > Piri;U,407 > TJ us 6r:v, .4-4) - I Z 3. 0' $ �30
,Pass ❑ Fail Inspector I. 111 ` -27 Date Vti (7ci
,J v,PT 5-rx rn N 6r 4.kC C`_-- i PM.
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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