Well Construction Permit

Well Construction Permit
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415 N 6 Street, Bldg 8, Shelton WA 98584,
Shelton: (360) 427-9670 ext 400  Belfair: (360) 275-4467 ext 400  Elma: (360) 482-5269 ext 400
FAX (360) 427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number
Payment Information
WEC
Receipt Number _________
 Cash
 Check
_____________
Date of Payment ________
Instructions
1. Complete Part 1. Incomplete applications will be rejected
2. Attach a plot plan and vicinity map.
3. Submit this completed application with appropriate fee a
minimum of 24 hours in advance of initiating well
construction. Refer to Mason County Environmental Health
fee schedule for cost.
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
Start Card #
Drilling Firm
Phone
Applicant
Phone
Mailing Address
City
State
Zip
Parcel Number
Directions to Site
Is the well site within 100 feet of salt / seawater?
Yes
No
If yes, a variance from DOE is required. Have you applied / received (circle one) a variance?
Yes
No
Applicant / Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES
NO
TAG #
Called In
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
Pass
Fail
Inspector
Date
This form may be scanned and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Construct a Well.docx
Revised: 12/1/2015
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