1.6.12 Well decommision noi.pdfNotice of Intent to
Decommission a Well
Notification Numbe
DEPARTMENT OF
ECOLOGY
State of westdngten
This form and required fees MUST BE RECEIVED by the Department of Ecology AE15979
72 HOURS BEFORE you construct a well.
Submit one completed form for each job site and required fee (check or money order only) to:
Department of Ecology Cashiering Unit, P.O. Box 47611, Olympia, WA 98504-7611
NOTE. Please print Processing your Notice of Intent may be delayed if all fields are not filled In completely.
1. Property Owner
Phone Number
First Security Bank
ai in Address
620 Edmonds Way
City
Edmonds
Stat%
A
Zip ode
8020
2. Agent (if different from above) AESI Phone Number (425) 827-7701
Cod
Mailing Address 9115th Ave City Kirkland TS6WA Zlp 9804
3. Well Location �-
Tax Parcel Number, Township, Range, Section,%, and 1/6 % are Required. Latitude and longitude (if available).
County Name
Snohomish - 31
Well Site Street Address
City
StateJ
Zip Code
620 Edmonds Way
Edmonds
WA
98020
Tax Parcel Number
Township
Range
Section
%. (within 16o acres) '/a
-'/4 (within 40 acres)
27N
3E
25
SE
SE
Latitude Degrees
Latitude Time
Horizontal Collection Method
min sec
Longitude Degrees
Longitude Time
min sec
4. Notice of intent Number of well Unique Well Tag Number of well
being decomissioned being decomissioned (if applicable)
5. Well Type to Decommission
Resource Protection- $20.00 each Revised Code: 027-WELT"'-02-87-000101 How Many?
6. Estimated Decommission Start Date i2115/2011 Project Name
7. Professional's License Number
8. Well Drilling Company Name Boretec Inc I Phone Number () 999-8101
9. Well Driller Name Driller License Numb 5
ROBERT SHELDON I
10.
Please copy the notification number (located in the upper and lower right corners) and keep in a safe place. Use
this reference number when communicating with the Department of Ecology.
Water Well : $50.00
Soil Sampling, Dewatering,
This notification number must be provided to your driller:
Environmental Investigation wells: No Fee AE15979
All other wells: _$20.00 each
Amount Enclosed $
Your validation will be sent to the e-mail address you provided: jim.boretec@g comQ v R.
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ofIntent Number
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