HomeMy WebLinkAboutWEC2025-00098 - WEC Application - 10/6/2025 Man VW'
c��""` '`^'1'b O 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY AUG 2 2025 L SHELTON: 360-427-9670, EXT.400
I l i BELFAIR: 360-275-4467, EXT.400
COMMUNITY SERVICES
=., •�^ ELMA: 360-482-5269, EXT.400
•vh . Iduilding,Nlanning,Environmental Health,Community Health BY: 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 0)5 _�� b 2. Attach a plot plan and vicinity map.
C)I.Ia v El Cash
' 3. Submit this completed application with appropriate fee a minimum
�- Check of 24 hours in advance of initiating well construction. Refer to
3�, Date of Payment Mason County Environmental Health fee schedule for cost.
C 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification r I
Site Address -NI0l - ' 1.1 0-
JT/� Start Card # w
Drilling Firm tO0t'V tS Di) I I i Il f Phone 3(,.00-2,75-- (z,,
Applicant ,tyc1 IA ,'&A)3OY\ QQ Phone
Mailing Address ‘ • . aX z 61r/' U Q
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City � 1 ,>� Y-'�-� r( State \A Zip 1 U 34-S-
Parcel Number 22U0I'7 U°OL{° asin O r 004
A Iivt f n^
Directions to Site r't O It . 'LI a4 ' _ ACC n 1 � �-
rn"o" bh
u .
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Is the well site within 100 feet of salt/seawater? ❑Yes Jo S i Orr. Q_
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 restrictions arJd additional fees ay 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 qN25' - `1 /T
❑ Driller on Site? /0/2_
❑ Z Is the well capped and Vented?
El Is there evidence of a surface sea
,Q' ❑ Is there a 2" annular space on all sides of the casing? L/ 7 2 c! 5 -S `')
❑ ❑ Has the seal slumped? NI c i • �� ' -2:-‘❑ .� Is the well flowing or is there evidence of other leakage? — ( Zy
❑ Is there evidence of cascading water?
❑ j2r- Is there evidence that the seal is at least 18 feet long?
,r ❑ Do the well site set-backs appear to be appropriate? L< (.
Comments p� 00- `allj/ C�,l ex. 0n( l I4 ID `± ip A, i0 '`"-
` t r ,_ Date 10 i�rZJ�
❑ Pass ❑ Fail Inspector �vt7 �G.cth tll Kai V I ef 4
This form may be scanned and available for tniblic view on the Mason County Web site. Revised:2/7/2018
Mason County WA GIS Web Map
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