HomeMy WebLinkAboutWEC2025-00046 - WEC Well Report / Log - 4/7/2025 IICCMIITIV votAR.5 rc*; Nrzribni
811 APR 0 7 2025
BY: 2rs-N-6TH STREET, SHELTON,WA 98584
/_' . MASON COUNTY SHELTON: 360-427-9670, EXT. 400
'll' 'l, COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
', ELMA: 360-482-5269. EXT. 400
r ` Building,Plann ing,Environ mental Health,Community Health_Ill'M1�3j 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 2. Attach a plot plan and vicinity map.
`moo�1 P3
Q� of Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
L-1 ( Date of Payment q_i1,74a5 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 72..8 Su.'5e,- 1-41,LL 1C2. -/cSikeiffYI1 98s'y Start Card# W ES ?sief
Drilling Firm Kyl s W ctk UAL") Phone
Applicant COAX l JS Phone 3te0-TSQ- 1 e i q
Mailing Address 3142 5e Ne.ISon
City %S i c r State Lit\ Zip l as-S it
Parcel Number 22l - 4,3 -o o o O O
Directions to Site Ctot l.- Lo 4/?-4/int 21 •1" !J 127• Sa • 4 L✓
e^ '/C.40%21-24' a, —122 .911'f083) into ma-PS
Is the well site within 100 feet of salt/seawater? ❑Yes igiNo
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes XNo
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 additional 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 '1 I I5"(L$ Fa 2 4' 1So
❑ ❑ Driller on Site?
❑ ❑ 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?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments �V 0 1— I S S
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/20I8
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