HomeMy WebLinkAboutWEC2025-00062/CONSTRUCTION OF A WELL - WEC Application - 6/4/2025 �NE�TWII9 �tt-E"-csN VA
"y~ Y```'. MASON COUNTY MAY 2 2025 415 N 6T"STREET,SHELTON,WA 98584
+ l SHELTON:360-427-9670, EXT.400
l ,I I. c COMMUNITY SERVIC BELFAIR:360-275-4467,EXT.400
\°z, .;y evading,Punning,Envir«mental Heahh,CommunityHeal� ELMA:360-482-5269, EXT.400
a,,. By T_ ; 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 Number ZOL. 2. Attach a plot plan and vicinity map.
Z4.72-5'. ^ 0 Cash 3. Submit this completed application with appropriate fee a minimum
i Check of 24 hours in advance of initiating well construction. Refer to
000(4 Mason County Environmental Health fee schedule for cost.
Date of Payment 65'!2- 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification / /� / ,t /- 6
Site Address cQ/ )t/ S Z-J. l,��' 44"�/ /� Start Card# 44 ( 6'96 93
Drilling Firm e71570/44...•c 7 ei-- 0,'.`) 1 sl/'�4 Phone 340 �9-967
Applicant a r.`,�.e, )7) L ch J Phone - 3.06--4,231
+19.241
Mailing Address 1,5-sv3 Ca.'rovs G) -la". _
City G'i.—A)/O/7 £m G14-2, State �/¢• Zip liar
Parcel Number 4 7 J sB�//o.. ' 2 ,9j Z)
Directions to Site
• Is the well site within 100 feet of salt I seawater? ❑Yes Jo
If yes, a variance from DOE is required. Have you applied I received (circle one) a variance? ❑Yes Quo!
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 . onal fees may apply to all new wells drilled after January 19'",2018 per ESSB 6091.
Applicant I Agent Signature I
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In5/ v' S. �p- ii i117- S
a ❑ Driller on Site?
0 -LI Is the well capped and Vented?
0 skill , Is there evidence of a surface seal? PMCCIZETTMcr
CI % Is there a 2"annular space on all sides of the casing?
0 0 Has the seal slumped? /" , " MAY 12 2025 L
❑ � Is the well flowing or is there evidence of other leakage?
❑ Jam' Is there evidence of cascading water? BY:
❑ Is there evidence that the seal is at least 18 feet long? c/7. / g y1-1 '7 (. .---
Er ❑ Do the well site set-backs appear to be appropriate? ,
1 �3 : IZS3 `103
Comments
❑ Pass ❑ Fail Inspector *.. Date I (i.(7- V-
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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