HomeMy WebLinkAboutWEC2025-00061 - WEC Inspections - 5/9/2025 yALLy0
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r o;..,-- "t:; 5 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY . MAY 121025 SHELTON:360-427-9670, EXT.400
1"' -I COMMUNITY SERVICE BE FAIR:360-275-4467, EXT.400
:360-482-5269, EXT.400
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;,,r ', s Building,Planning,Environmental Health,Community Health By + FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information I Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 20Z6- - 2. Attach a plot plan and vicinity map.
20Zr. 0 Cash 3. Submit this completed application with appropriate fee a minimum
`? t< Check of 24 hours in advance of initiating well construction. Refer to
0 I Mason County Environmental Health fee schedule for cost.
` Date of Payment d5��2�25 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification / q+
Site Address 1 f ( /l47 ? I,' S 1Lec, 6D Start Card# i' 9�9Y
Drilling Firm mO/'/4--14fe k tD r ) I i J-, Phone S40 `Se.90. 9ri9193--
Applicant MA, 74-j4'e i ' A. Yy, Phone ydo`97 d fr-c? //
Mailing Address (cO E. ,4�,he cs-4ep e 0 I"
City ,4/1x)7 State �Q Zip 98'9a2 V
Parcel Number /,,24,9/ 7 S-0 93 7
Directions to Site
4 Is the well site within 100 feet of salt/seawater? ❑Yes — ��
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes Dtvo
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 restrictions and itional fees may apply to all new wells drilled after January 19`^, 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# Called In 9(2-E (zs Fc 2 2-2_
❑ Driller on Site? &PG'- t__,.
❑ 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? Fezmnvimil
❑ ElHas the seal slumped? AD+ obsA.w-mil
❑ `� Is the well flowing or is there evidence of other leakage? MAY 12 2025
El le Is there evidence of cascading water?
❑ Is there evidence that the seal is at least 18 feet long? AAA r�,A BY:
AI ❑ Do the well site set-backs appear to be appropriate? bb 54- t
Comments
IQ Pass ❑ Fail Inspector WY 1 �{ Date M2V1 IS
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This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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